Clinical Clerkship PDF

a clinical clerkship guideline for everyone
Disclaimer : the author do not accept any responsibility or legal liability for any errors in
the text or for the misuse or misapplication of material in this work
Edited by CSMU HOW medical team Page 1

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 distress
I. tachypnoea (>20 brath/minr)
ii. flaring of the nasal alae
iii .pursed lips
iv. use of accessory muscles
v. subcostal & intercostal muscle retraction
vi. cyanosis (in sver resp. distrss)
7. Hydrational status - examine the tongue, mucous rnernbran, skin turgor, sunken eyeball
8. Nutritional status
-cachexic/obese (check BMI)
-any obvious muscle wasting? (look at temporal muscle, vastus muscles & small muscles of the
hand / interosseous mus.)
9. Gross deformity
10. 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, no
gross 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. Introduce
ii. Permission
iii. 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 time
i Palms
Moisture - dry @ moist
Temperature - warm @ cold
Colour - pink @ pale
ii. Fingers & Nails
cyanosis - peripheral cyanosis
capillary refilling
clubbing
*note: stage of clubbing
stage I - loss of angle between nail & nail bed
stage II - increase longitudinal & transverse curvature
stage III - positive fluctuating test
stage IV - drumstick appearance
*note: cardiovascular causes of clubbing :

- Bacterial endocarditis
- Cyanotic congenital heart disease
infective endocarditis stigmatas - splinter haemorrhages, Oslers nodes,

Janeway lesion
iii. Pulse
Rest the patients hands on the abdomen while palpating, count the pulse rate.for 30
seconds, 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. Neck
access the jugular venous pressure
0
- 45 , head is turned away from the midline (to relax the sternocleidomastoid muscle), detect a
pulsatile movement, differentiate it from carotid pulsation, measure it, assess the character if
abnormal.

-4 steps to distinguieh from carotid pulsation (need to be done before commenting that the JVP is
elevated
1; palpate it. venous pulse is visible but not palpable
2; deep inspiration; JVP .decrease on / with inspiration
3; 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. Head
1, Eyes
- conjunctiva; pink ~ pale
- sclera; jaundice
2, Mouth & Tounge
- tongue; moist, dry @ coated
- central cyanosis
- dental hygiene
3. Face
- malar flush (in mitraI stenosis)
D. Lower limb
I. pitting oedema
- look at the patients face, press on the tibial prominence on both sides for 15 seconds, and
extend 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 pericardium

A. 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. Palpation
i. apex beat (mitral area)
- search for apex beat - start palpating from the most inferior lateral region & inch
up 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. obesity
b. pleural & pericardial effusion
c. chronic obstructive airway dss (emphysema @ chr bronchitis)
d. shock
e. 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;

st nd
a. 1 & 2 heart sound & their intensity (soft, normal@loud)
b. extra heart sound (S3 and S4)
c. murmur
d. other additional heart sound (e.g., opening snap, systolic injection click)
nd
e. fixed splitting 2 heart sound (only in pulmonary area -- -atrial septal defect)
If theres murmur, few features should be commented

i. timing
ii. the area of greatest intensity
iii.radiation
*note: sites of radiation of murmur
1. mitral regurgitation left axilla
2. aortic stenosis right side of neck
3. aortic regurgitation left sternal border
iv.grading
v. 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 radiat ion to the axilla.
Graded 3/6 and is accentuate during inspiration and on left lateral position -
5. Other relevant systemic examination

1. 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 failure
a. 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 for Roths spots in retina (in infective endocarditis)
- look for hypertensive retinopathy
the Keith - Wagener classification for retinopathy;
Grade 1: arterial narrowing & increase tortuosity
Grade 2: arteriovenous nipping
Grade 3: haernorrhage & soft exudates
Grade 4: Grade 1-3 + papilloedema

EXAMINATION OF THE RESPIRATORY SYSTEM
1. Repeat 5 important points before examine the patient, IPPEC:

1. Introduce
2. Permission
0
3. Positioning - prop up to approx 45
(2 reasons: 1. to access JVP 2. pt may have orthophoea)
4. Exposure
o expose head, neck, upper & lower limbs adequately for general
o examination
o 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 examination
A.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 clubbing
A. lung abscess
B. bronchoectasis
C. lung carcinoma, cystic carcinoma
D. emphysema
E. 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 T 1
intercostal 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 asthma
b. constrictive pericarditis
c. pericardial effusion
d. cardiac tamponade
vi. Blood Pressure

if necessary, quality paradox in mmHg

vii. Flapping Tremor
- occur in carbon dioxide retention
B. Head
i. eyes
anaemic?
jaundice?
evidence of Homers 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 discharges
iii.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 cough
ask the pt to cough 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 obstruction
iv. feel the distance from the cricoid 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 defect
4 Harrisons sulcus: a linear depression of the lower ribs at the diaphragm attachment site,
suggesting chronic childhood asthma or rickets
5. kyphosis: increase forward spinal convexity
6. scoliasis: a lateral curvature
c. scars?
- Including previous surgery & chest drains
d. dilated veins?
- occur in superior vena caval obstruction in lung neoplasm at the hilum
e. 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
examination
a. chest expansion
- place the hand firmly on the chest laterally after a full expiration with the fingers apart and
thumb 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
- pneumothorax
ii. 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 collapse
C.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 nature
b. 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 sound
i. intensity (compare on both sides, either normal, reduced or absent)
- causes of reduced breath sound include chronic airflow limitation (esp. emphysema ) pleural
effusion, pneumothorax, pneumonia, a large neoplasm and pulmonary collapse
- causes of absent breath sounds are pleural effusion, pneumothorax or collapse
ii. nature (vesicular @ bronchial breath sounda)
*note: natures of breath sound
1. 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 failure
2. 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 move
the 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 left
lower zone.

Examination of gastrointestinal system

1.Introduce
2.Permission
3.Positioning - lying flat with 1 pillow
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)
A. Upper limbs - examine both sides
i. Palms
- Moisture - dry @ moist
- Temperature - warm @ cold
- Colour - pink @ pale
*note: Some GIT cause of anaemia
a. 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
- palmar erythema
*note: causes of palmar erythema
1. physiology
- pregnancy
- puberty
- familial
2. pathology
- chronic liver dss
- rheumatoid arthritis
- thyrotoxicosis
- oral contraceptive pill
- polycvthaemia
ii. Fingers & nails
- clubbing
*note : GI causes of clubbing
a. cirrhosis (esp biliary cirrhosis)
b. inflammatory bowel ds
c. coeliac ds
d. GI lymphoma
e. chronic active hepatitis

- leukonychia (white nail d/t hypoalbuminemia)
*note : causes of hypoalbuminemia
1. reduce intake malnutrition
2. reduce absorption malabsorption
3. reduce synthesis liver ds
4. increased loss nephrotic syndrome
Severe burn
Protein losing enteropathy
Chronic ds ( sg: malignancy)
- koilonychia (spoon-shape nail in iron deficiency anemia)
iii)pulse - rate
- rhythm
- volume
iv)Forearms and amrs look for arthritis, bruise ecchymosis etc
- stratch markds (d/t pruritus in obstructive jaundice, esp in biliary cirrhosis and lymphoma)
- bruising (clotting abnormalities d/t liver failure and obstructive jaunice)
v) blood pressure
vi)flapping tremor (asterixis) ask pt put both hand straight with little hyperflexion on
wrist, +ve if fingers flex forward
- occur in hepatic encephalopathy
*note : causes of flapping tremor;
a. liver failure
b. respiratory failure
c. renal failure
d. hypoglycemia
e. hypokalemia
f. hypomagnesaemia
g. barbiturate intoxication
B) head
i. eyes
- conjunctiva; pink @ pale
-sclera; jaundice?
ii. mouth & tongue
- tongue; moist, dry @ coated
- color; pink or pale
- central cyanosis
- glossitis (in iron deficiency & megaloblastic anemia)
- angular stomatitis (in vitamin b6, b12, folate & iron deficiency)
iii. Breath
- fetor hepaticus ( a sweet smell in severe hepatocellular disease)
C) chest wall and axilla
i. spider naevi usually at upper chest, above nipple line, s/t can see on arms and back
- small redden spots, a central arteriole with leg-like branches
- blanch on central pressure whitening from centrally peripherally
* if from peripheral central, its telangiectasia
- arise in the distribution of the SVC (arm, neck, upper chest and back)
- more than 3 suggest underlying chronic liver disease, pregnancy or hyperthyroidism
ii. gynaecomastia plapate breast tissue and glands
- for male only
- d/t increase in estrogen/ androgen ratio
*note: causes of gynaecomastia;
1. liver ds
2. testicular tumor(estrogen increased)
3. hyperthyroidism
4. drugs estrogen, digoxin, spironolactone, cimetidine

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 to
the 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 lump
c. 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 Medusa
g. skin discoloration
- e.g. : bluish hue in Cullens and Grey Turners sign in acute pancreatitis, purple coloured striae
in Cushing syndrome, ascites and pregnancy
h. 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 for
a. 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 tenderness
ii. palpate for masses
iii.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. site
2. shape
3. size
4. surface (smooth, regular @ irregular)
5. consistency (soft, cystic, firm @ hard)
6. edge (regular @ irregular)
7. tenderness
8. 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 mass
12. percussion notes (& its continuity with surrounding structures)
13. fluctuation test & fluid thrill (if cystic)
- besides, it is important to decide

1. 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 mass
but 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 his
shoulders from the bed orto raise both the extended legs from the bed. if the
mass 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 viscera

a. 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 is
6th 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 the
left 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 rib
cage

- if spleen palpable its increase 2x size of normal spleen
*note: criteria needed for palpable spleen;
1. size
2. edge
3. splenic notch
4. surface
5. consistency
6. 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, normally
tympanic 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 rectus
ii.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. Auscultation
a. 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 bruits
place 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 gastrointestinal
malignancy, 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 tremor
2. fetor hepaticus
3. cough impulses
4 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 liver
was palpable 3 cm below the costal margin, it was firm in consistency, smooth in surface, well defined in
margin, non tender and non pulsatile. There was no bruits heard. The spleen and kidneys were not
palpable. Shifting dullness was negative. The bowel sounds were present and normal intensity. There
were no renal bruits.

Examination of genitourinary system

1.Introduce
2.Permission
3.Positioning - lying flat with 1 pillow
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 exomplexion
iii. hyperventialtion (metabolic acidosis)
iv. hiccups
v. abnormal movements
A.Upper limbs - examine both sides
i. Palms
- Moisture - dry @ moist
- Temperature - warm @ cold
- Colour - pink @ pale
*note : some GUT causes of anaemia

a. poor nutrition (esp folate deficiency)
b. blood loss
c. erythropoietin deficiency
d. hemolysis
e. bone marrow suppresion
f. chronic ds
ii. Fingers & nails
- 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. in
gout
- signs of peripheral neuropathy
v. Arteriovenous fistulae and shunt
vi. Blood pressure: lying & standing if hypovolemia is suspected
vii. Flapping tremor: asterixis, in uremic encephalopathy
B.Head
a. Eyes: - jaundice?
- anemic?
2+
- band kerotopathy? (d/t Ca depositions beneath corneal epithelium)

b. Mouth & tongue:
-tongue: moist, dry or coated?
-central cyanosis
c. Breath: urernic fetor
C. Neck: assess JVP

Renal angle tenderness
D. Lower limbs:
1. pt sit, arm across chest
- Pitting edema th
2. upper border 12 rib
- Bruising
Lower border L : L2
- Pigmentation
R : L3
- Scratch marks
3. put thumb over renal angle (btw
- Tophi th
12 rib, lateral to sacrospinous
- Signs of peripheral neuropathy or myopathy
mus.)
- Peripheral pulses
4. make jabbing movement(push
hard with thumb
4. Specific examination (abdomen):
- As in Specific examination of abdominal in GIT system
* pasternatsky sign :
- Plus extra examination:
+ve if tenderness present
Peritoneal dialysis scars
Renal 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 retinopathy
D. Urine dipstick test: check for unnary tract infection

EXAMINATION OF NERVOUS SYSTEM
Repeat 5 important points before examine the patient, IPPEC:
I. Introduction
2. Permission
3. 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 present
c. consider where (what level) the lesion is
2. General inspection, PCLC PR HNG MA

3. General Examination
4. Neurological Examination
A. Mental state examination (MSE): higher centers assessment
-assess the following (briefly)
i. Level of consciouness
Acute, reversble delirium
ii. Orientation to time, place and person
Chronic, irreversible dementia
iii. Short & long term memory
iv. General knowledge
v. Posture
vi. Abnormal movement, e.g:tremor
vii. Handedness
viii. 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 hand
movements or perception of light.
Color vision
Visual field (Confrontation)
- test each 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 pin from
beyond 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

the center of the visual field of each eye. A more precise method of mapping the peripheral
fieldsperimetry.
Pupils:
- inspection: when the patient is looking at an intermediate distance, examine the pupil for size,
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 ptosis
b. motor supply to all orbital muscle except superior oblique and lateral rectus muscle, if
defect failure of certain movement, diplopia, nystagmus
c. parasympathetic tone to papillary reflex, if defect loss of light and accommodation
reflexes
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 of
eye movement, diplopia (in any direction of gaze), nystagmus (most commonly horizontal
flickering 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 region
2. corneal reflex
3. motor supply to mastication muscles: look for any wasting of temporal and masseter
muscles. Ask patient to clench teeth and palpate for contraction of the masseter and
temporalis 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:
- sensory sensation 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
- motor supply 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 the
corner of the mouth
b) ask the patient to wrinkle his forehead by Iooking upwards while you try to feel the muscle
strength (frontalis), close eyes while you attempt to open them (orbicularis oculi), blow the
cheeks oUt while you press the cheeks (buccinator) and show the teeth (orbicularis oris)

2. taste sensation: usually not examined but asked the patient if he has noticed any recent
change
3. hearing sensation: usually not examined but asked the patient if he has noticed any hearing
problem (stapedius mus.)
In lower motor neuron lesions all muscles are affected, in upper neuron lesions, the upper half
of 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:
- sensory to pharynx, carotid sinus and taste to posterior 1/3 of tongue
- rnotor supply to stylopharyngeous muscle
- parasympathetic: parotid gland
CN 10:
-sensory to larynx
-rnotor supply to cricothyroid 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 pulled
towards normal side)
by using spatula, test gently for gag reflex (not usually done) to check 9th sensory, 10th motor ask the
patient 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 limb
1. Motor system (IPT PRC)
a. Inspection (SSS WAA DF):
-skin
-scar
-symmetry
-wasting
-attitude and posture
-abnormal movement
-deformity

- fasciculation: if no fasciculation is seen, tapping over the bulk of brachioradialis and biceps muscles
with tendon hammer
b. Pronator drift
Ask patient to hold his/her arms outstretched with palms facing upwards then ask patient to close
their eyes
The weak arm gradually pronates and drifts downwards
Only 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 joints
2. 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 adduction
II. flexion and extension of arm
Ill, elbow flexion with hand fully supinated and with the hand in mid position
IV. elbow extension
V. fingers flexion and extension
VI. fingers abduction and adduction
VII. thumb opposition
VIII. 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 pointing
ii. rapidly alternating movements: slow and clumsy in dysdiachokinesia (inability to perform rapid
alternating movements)
iii. rebound
2. Sensory system
a. Pain:
- Test lateral spinothalamic tract

- 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 normal
sensation
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
neuropathy
e. temperature:
- lateral spinothalamic tract
D. Lower limb
1. Motor system( IT PRC)
a. Inspection: (SSS WAA DF)
b. Tone and cIonus
- Tone: relax the patient,then:
i. alternately flex and extend knee joint
ii. 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 hypertonia
c. Power:
- test the following movements
i. Hip flexion and extension Hip flexion - psaos, iliacus (L2, L3)
ii. Hip abduction and adduction Hip extension gluteus maximus (L5, S1, S2)
iii. Knee flexion and extensipn Hip abduction gluteus medius, minumus, tensor fasciae latae
iv. Dorsiflexion and plantar flexion (L4,L5,S1)
v. Toe extension and flexion Hip adduction adductor longus, brevis, magnus (L2,L3,L4)
d. 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 lesion
e. Coordination: heel shin test
2. Sensory system:
- Test pain, light touch, joint positiOn and vibratiOn sensation as in the upper limbs

E. Gait and Rhombers test:
Ask the patient to get up from the bed
Then ask the patient to
i. Walk normally
ii. Walk heel-to-toe, to exclude a midline cerebellar lesion
iii. walk on toes, to test SI
iv. Walk on heel, to test L5
v. Stand up from squatting, to test proximal myopathy
st
vi. Stand with heels together, 1 with 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

EXAMINATION OF HAEMATOLOGICAL SYSTEM
Repeat 5 important points before examine the patient, IPPEC:

1. Introduction
2. Permission
3. Positioning:
- Lying flat with 1 pillow
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
2.General examination PCLC PR HNG MA

3.General and specific examination:
A. Upper Iimbs
a. 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

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 for splenomegaly, hepatomegaly and paraaortic nodes enlargement and
ascites
Perform per rectal examination: for tumor or bleeding
External genitalia examination to look for testicular infiltration in leukemia
E. Lymph nodes:
Ask the patient to sit up
Check:
i. Epitrochlear nodes
ii. Axillary nodes
iii. Cervical and supraclavicular nodes
iv. Inguinal nodes
Check the extent, sizes, consistency, tenderness, flexion, mobility and overlying skin
F. Bone: look for bony tenderness
G. Fundi: look for hemorrhages
*Note : Causes of Iymphadenopathy

1. 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 splenomegaly

1. Massive: 2. Moderate:
CML Above causes
Myelofibrosis Portal hypertension
Malaria Lymphoma
Kala-azar 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

EXAMINATION OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
I. Repeat 5 important point before examine the patlent, IPPEC:

1. Introduce
2. Permission
3. Positioning: lying flat with I pillow
4. Exposure: expose head, neck, upper and lower adequately
5. 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 treatment
B. Head:
a. Hair:
alopecia
lupus hairs: short broken hairs above the forehead
coarsea and dry
b. Eyes:
Jaundice?
Anemic?
Scleritis?

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 hepatomegaly
E. Cervical lymph node: sit the patient up
F. Chest and pericardium:
look for pericardial rub (pericarditis), pleural rub (pleurisy), pleural effusion, endocarditis
*Extra:
Look for proximal 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 for proteinuria, 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 limbs
2. Bruising and poor wound healing
3. Proximal myopathy
4. buffalo hump
5. bony tenderness and pathological features in osoporosis
6. psychosis
7. acne and hirustism
8. purple striae
9. edema: due to sodium and water retention
10. peptic ulceration
11. hypertension, aldosterone effect
12. DM, due to steroids which are diabetogenic
13. Avascular necrosis of femoral head

EXAMINATION OF THYROID GLAND
1. Introduce
2. Permission
0
3. Positioning - prop up to approx 45
1. to access JVP
2. For specific examination of thyroid gland
4. Exposure
o expose head, neck, upper & lower limbs adequately for general
o examination
o 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 wasting
ii. anxiety, frightened facies, irritable, incorperative
iii. 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. BP
g. 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

B. Head
i. Hair: coarse and thinning or alopecia in hypothyroidism
ii. Eyes:
I. Jaundice?: note the sclera will never become yellow in hypercarotenaemia
2. Anemic?
3. Signs of Horner syndrome:
a. thyroid swelling affecting the sympathetic trunk
b. signs including: ipsilateral partial ptosis, ipsilateral miosis, enophthalmos, ipsilateral
impaired sweating of the face
4. Features of hypothyroidism:
a. Periorbital edema
rd
b. Loss of thinning of the outer 3 of eyebrow
c. Xanthelasma
5. 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 position
ii. Caused by over activity of tbe involuntary (smooth muscle) part of the levator palpebrae
superior muscle
iii. Look for :
1. sclera visible above iris (Dalrymptes sign)
2. lid lag (Von Graefes sign) by asking the patient to follow a descend finger, the
delayed drooping of the upper lid is noted the descent of the upper lid lag be-
hind descent of the eye ball
*Note: Complication of exophthalmos:
1. chemosis
2. conjunctivitis
3. corneal ulceration(due to inability to close eyelids)
4. optic atrophy(due to optic nerve stretching)
5. ophthalmoplegia
6. protosis by standing behind the patient and looking downwards,
the eye will be visible anterior to superior orbital margin
7. Joffroys sign: absence of wrinkles on forehead when patient
looks upwards
8. StelIwags sign: staring look and infrequent blinking of eyes
9. Moebiuss sign: inability or failure to converge eyeballs
10. accomodation failure
b. Exophthalmos (proptosis):
i. Protrusion of eyeball out of orbit: the eyelids are retracted and sclera becomes visible
below or all round the iris
ii. Caused by increased in fat / edema I cellular infiltration in retro-orbital space during the
eyeball forwards
iii. 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 affected
iii. Paralysis of these muscles prevents the patient to looks upwards and outwards
d. Chemosis:
i. Edema of conjunctive
ii. The conjunctiva becomes edematous, thickened and crinkled
iii. Caused by obstruction of venous and lymphatic drainage of conjunctiva by increased retro-
orbital pressure

iii. Face: puffy face, skin thinning and doughy induration in hypothyroidism
iv. Mouth and tongue:
tongue moist, dry or coated?
central cyanosis?
tongue enlarged in hypothyroidism
tremor of protruded tongue in thyrotoxicosis
v. 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 lateral
c. Ascend during swallowing? Lower border of the gland can be noted?
Only goiter or thyroglossal cyst will rise during swallowing because attached to larynx, except
neoplastic 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 isthmus
e. Scars: thyroidectorny scar?
f. Prominent veifls:
Dilated veins suggest retrosternal extension of goiter (thoracic inlet obstruction)
g. Skin changes: skin discoloration, redness?
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
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

Relax the sternocleidomastoid muscles by slightly flexed the neck or rotates the neck towards
the side of palpation
To get more information about the particular nodules of thyroid gland, the patient is asked to
extend 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 swelling
b. size
c. shape: oval, round, irregular, uniform etc
d. 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 defined
g. tenderness:
caused by thyroiditis (subacute or rarely suppurative), bleeding into cyst or carcinoma
h. ascends on deglutition
i. to get below the gland:
feel the lower border because its absence suggest restrosternal extension
j. mobility:
in both horizontal and vertical planes
fixity means malignant tumor or chronic thyroiditis
k. temperature
I. attach to the overlying skin and underlying structures, including sternocleidomastoid
muscles
m. fluctuation
n. translucency
o. pulsation or thrill
Loheys method: stand in front of the patient, to palpate left lobe, thyroid gland is
pushed 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

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

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 goiter

1.Diffuse, homogenous goiter
hyperplastic (colloid goiter)
simple goiter
Graves disease
Thyroiditis, e.g. Hashimotos and subacute
2. Solitary nodule
Dominant nodule in multi-nodular goiter (50% cases)
Degeneration or hemorrhage into colloid cyst or nodule
Benign adenorna
Carcinoma (primary or secondary)

EXAMINATION OF THE BREAST

a. Introduce
b.Permission
c. Positioning:
0
45 or sitting
Sitting up for specific examination of thyroid gland
d.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 arms
e. Comfortable - make sure pt is comfortable
2. General inspection (PCLC PR HNG MA), and examination

3. 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 positions
b. 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 glands
and 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 sarcoma
c. 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
* look at 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, it
will also accentuate any depression in the skin causes by tethering or fixity to underlying lump.
Ask the patient to point out the side of pain or lump
st
Palpate the normal breast 1
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

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 skin
ii. 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 at
the 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 up
3. 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)
st
move the lump in the direction of the fibers 1 and 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 in
the same direction and compare the range of mobility
any restriction in mobility indicates fixity to the pectoral fascia and pectoralis major
b. 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 discharge
c. AxiIla and cervical lymph node

Look for distance metastasis
Common sites for secondary deposits:
a. Lungs
b. Bone(tenderness): ribs, spine, sternum pelvis, upper ends of femur and humerus
c. Liver

Examination of inguinal hernia

1.Introduce
2.Permission
3.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
A) 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

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 hernia
5) ring occlusion test
- with the swelling completely reduced, press on the deep inguinal ring (1/2 inch above the mid-point
between 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)

a. Abdominal examination:
Look for causes of increased intra-abdominal pressure; enlarged prostate (per rectal
examination), 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 scar
On 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

Discussion notes:
2 diagnostic signs of uncomplicated hernia:
1. Impulse on coughing
2. 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 below
the inguinal ligament
inguinal hernia bulges into corner of the mons veneris, above crease of the groin, where as
femoral hernia bulges into medial end of groin crease
inguinal hernia lies medial and above pubic tubercle whereas femoral hernia occur lateral and
below 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 backwards
Swelling 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

b. Omenturn (omentocele or epiplocele):
firm non-fluctant and dull to percussion
st
the 1 part goes in easily while the last part resent to be reduced
c. Intestine (enterocele):
soft, resonant and fluctuant may have bowel sounds
st
1 part often difficult to reduce but the last part slips in easily
d. Extraperitoneal fat
e. Bladder
5) Complication of the hernia:

a. Obstructed or incarcerated:
irreducible + intestinal obstruction
b. Strangulated:
irreducible + arrest of blood supply to the contents (may or may not have intestinal
obstruction)
c. Inflamed:
when its content such as appendix, salphinx or a Meckels diverticulum becomes inflamed

EXAMINATION OF THE VARICOSE VEINS

a. Introduce
b. Permission
c. Positioning: standing
d. Exposure: expose thigh (groin region) until toe
e. 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 examination

3. 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 fossa
b. Size: large, prominent, small and etc
c. Swelling:
localized: affecting a segment of venous system
generalized: mostly due to deep vein thrombosis
d. Skin, look for:
i. color:
redness indicates thrombophlebitis,
white indicates excessive edema and lymphatic obstruction, congested
blue indicates deep vein thrombosis
ii. ulceration, eczema and pigmentation: esp around mallelous
iii. edema or swelling might indicate deep vein thrombosis
iv. lipodematosclerosis: skin becomes thickened, fibrosis, scleroses and pigmented due to
chronic venous hypertension which causes fibrin accumulation
v. scars: due to venous ulcer or previous opening
vi. venous stars: blue patch which consist of minute veins radiating from a single feeding vein
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

the test is to dertermine incompetency of sapheno-femoral junction and/or the
communicating system:
i. Sapheno-femoral junction incompetent:
the vein remain empty, which is confirmed by release the pressure and vein quickly filled up
from above
ii. Incompetent of communicating system:
The tourniquet or pressure over the saphenous opening remains in place but there is
gradual 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 direction
A 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 are
blocked
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

- AbdominaI examination including rectal and vaginal examination to exclude any pelvic or abdominal
causes for varicose veins

Practically, not all the tests are done in the exam since most of the time it comes out in short case with
limited time. Therefore, there are only 3 important tests that, are required in the exam:
a. Schwartz test
b. Brodie-trendelenberg test, and
c. Perthes test
*Note: complication of varicose veins

1. hemorrhage (minor trauma to dilated vein)
0
2. phlebitis: occurs spontaneously or 2 to minor trauma
3. ulceration: mostly due to deep vein thrombosis rather than varicose veins alone
4. pigmentation
5. eczema
6. IipodermatoscIerosis
7. calcification of the vein
8. periositis in long standing ulcer over tibia
9. 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 valves
2. 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

Examination of hands
General 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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a clinical clerkship guideline for everyone

Edited by CSMU HOW medical team Page 1

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

Edited by CSMU HOW medical team Page 2

2. General Inspection (PCLC PR HNG MA)

*note: cardiovascular causes of clubbing :

infective endocarditis stigmatas - splinter haemorrhages, Oslers nodes,

Edited by CSMU HOW medical team Page 3

*note: causes of elevated JVP

4. Specific examination of the pericardium

Edited by CSMU HOW medical team Page 4

for every auscultation, listen for;

If theres murmur, few features should be commented

Edited by CSMU HOW medical team Page 5

5. Other relevant systemic examination

Edited by CSMU HOW medical team Page 6

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

2. General inspection; PCLC PR HNG MA

vi. Blood Pressure

Edited by CSMU HOW medical team Page 7

*note: causes of the trachethl deviation

Edited by CSMU HOW medical team Page 8

4. Specific examination (of the chest)

*note: Examples of the chest wall deformities:

Edited by CSMU HOW medical team Page 9

Edited by CSMU HOW medical team Page 10

Edited by CSMU HOW medical team Page 11

1. Repeat 5 important point before examine the patient, IPPEC:

2. General inspection; PCLC PR HNGMA plus;

Edited by CSMU HOW medical team Page 12

Edited by CSMU HOW medical team Page 13

5. specific examination (of the abd)

B. Palpation and percussion

Edited by CSMU HOW medical team Page 14

- besides, it is important to decide

*note : how to differentiate between extra & intra abdominal mass?

Palpate the solid viscera

Edited by CSMU HOW medical team Page 15

Spleen Left kidney

Courvoisiers law palpable GB + obstructive jaundice + non-tender

Edited by CSMU HOW medical team Page 16

Edited by CSMU HOW medical team Page 17

1. Repeat 5 important point before examine the patient, IPPEC:

2. General inspection; PCLC PR HNG MA plus;

*note : some GUT causes of anaemia

Edited by CSMU HOW medical team Page 18

C. Neck: assess JVP

5. Other relevant examination:

Edited by CSMU HOW medical team Page 19

*note: the approach is to:

2. General inspection, PCLC PR HNG MA

B. Cranial nerves examination:

Edited by CSMU HOW medical team Page 20

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

Edited by CSMU HOW medical team Page 21

vii. CN 9, 10 (Glossopharyngeal & Vagus):

Edited by CSMU HOW medical team Page 22

Edited by CSMU HOW medical team Page 23

c. Joint position sense:

Edited by CSMU HOW medical team Page 24

Edited by CSMU HOW medical team Page 25

Repeat 5 important points before examine the patient, IPPEC:

2.General examination PCLC PR HNG MA