Physical Diagnostic

Terms
1. Pitting edema: It is swelling of the tissue due to excess fluid in which the fingertip pressure
leaves temporary indentation in the skin.
2. Melena: The production of black, shiny, sticky, foul-smelling, tarry stools.
3. The first heart sound: Signaling onset of systole, closure both mitral and tricuspid valve,
low pitch, long duration, best heard in apex area.
4. The second heart sound: Signaling onset of diastole, produced by closure of both aortic and
pulmonary valve.
5. The third heart sound: Being low in both frequency and intensity, it is best heard with the
bell of the stethoscope. Occurs during the phase of early diastolic filling about 0.12 to 0.14
second after S2. This sound heard in most children and some adults.
6. The fourth heard sound: Also low in frequency and intemsity. Like the third sound, it is
best heard in the apex.
7. Continuous fever: Fever cause show the high temperature 39-40°C may continue for days /
weeks with fluctuation less than 1°C between morning and night.
8. Remittent fever: Similar to continuous fever, but the swing of temperature is greater than
2°C and the temperature does not fall to normal (rheumatic fever).
9. Intermittent fever: The temperature rises every second or third day at approximately the
same time. The temperature rises abruptly to about 40°C for a few hours only and then falls
abruptly to normal or below (malaria).
10. Undulant fever: The temperature chart shows up rises up to 39-40°C, lasting for 7~14 days,
falling to normal for about the same period but recurring over many weeks or months.
11. Relapsing / recurrent fever: the temperature rises abruptly to 39°C or above for a few days
then falls abruptly to normal (Hodgkin’s disease).
12. Kussmaul’s respiration: A metabolic acidosis. Deep, long, but regular respiration caused by
center stimulate by acid substance. E.g diabetic ketoacidosis.
13. Reffered pain: Pain and discomfort that is perceived at a site distant from affected organ
because of overlapping transmission pathways. Characteristics: accurate localized, severe
tenderness and muscular tension.
14. Board like abdomen: Indicates inflammation of underlying peritoneum which reflexly
establishes spasm of abdominal muscle. Involved area feels wooden pr board like. Maybe
seen in fear and voluntary muscle tension.
15. Three depression sign: Supraclavicular fossa, suprasternal fossa, and intercostals space.
16. Pericardial knock: Extra sound heart in diastole shortly after s2. Its heart best in the apex or
left lower parasternal area.
17. Third degree A-V block: Atrial and ventricles rate beat dependently because the stimuli
cannot pass AV junction, the atrial rate is faster than ventricular rate and PR-interval is
constantly changes.
18. Jaundice: Yellow discoloration of sclera, skin, mucous membrane due to deposition of bile
pigment.
19. Dyspnea: An abnormally uncomfortable awareness of breathing or difficult, labored,
uncomfortable breathing.
20. Chief complain: Symptom that represent the primary reason for seeking health care.
21. McBurney’s Point: The point over the right side of the abdomen that is one third of the
distance from the anterior superior iliac spine to the naval.
22. Sternal angle: 5 cm below suprasternal notch. It’s anterior anatomic landmark, adjacent to
2nd rib, T5 vertebra, tracheal division, upper border of left atrium and border of upper and
lower mediastinum.
23. Wenckebach phenomenon: Increasing prolongation of PR interval occurs until a P wave is
blocked and not followed by QRS complex.
24. Complete compensatory pause in premature contraction: A long interval following a
premature ventricular contraction but does not disturb the normal sinus pacing of heart.
25. Hematochezia: the excreted of blood from rectum occurs after the hemorrhage of digestive
tract.
26. Osmotic diarrhea: It is caused by accumulation of osmotically active solutes in the gut
lumen; stool volume decrease with fasting and can be seen in laxative abuse, fat
malabsorptioon.
27. Pre-excitation syndrome (WPW syndrome): ventricles of the heart become depolarized
too early which leads to their partial premature contraction.
28. Cough and expectoration:
Cough: Essential defense mechanism that prevent airway from foreign substances and clear
the excretion of respiratory tract.
Expectoration: Pathological phenomenon that human being remove the pathological
secretion from respiratory system by means of coughing.
29. Diarrhea: An excessive frequency in the passage of stools that are usually unformed or
watery. The stool weight is greater than 200gr.
30. Murphy’s sign: A sharp pain and arrested inspiration that found in acute inflammation of
gallbladder (acute cholectitis).
31. Gallop rhythm: Condition in which 3 and occasionally 4 heart sounds are spaced to audibly
resemble the canter of horse.
32. Starling’s law: Force of blood ejected by heart is determined by primarily by length of the
fibres of its muscular wall.

Fill in the blanks

1. Mechanism of abdominal pain include visceral pain, somatic pain, and referral pain.
2. According to pathophysiology, diarrhea can be divided into osmotic diarrhea, mixed-
secretory diarrhea, mucosal inflammation and motility disturbance.
3. The duration of acute diarrhea is less than 2 weeks.
4. For descriptive purposes, the abdominal cavity is generally divided into four quadrants or
nine areas.
5. Massive hemoptysis can be seen most positively in the patient with the cancer.
6. The most commonly seen causes of hematemesis are peptic ulcer disease, gastropathy,
gastric esophagus varices, and gastric cancer.
7. The main sources of billirubin production is from RBCs. The billirubin should be uptaken in
the organ liver.
8. In medicine, diagnosis is the recognition of a disease or condition by its outward symptoms
and signs.
9. Cough without sputum is called dry-cough. It is usually called by acute pharyngitis.
10. Cough with hemoptysis is commonly seen in bronchial disease, pulmonary disease,
cardiovascular disease.
11. The quadrants system divide abdomen into following sections: right upper, right lower, left
upper, and left lower.
12. Collateral circulation of portal hypertension mainly includes esophageal plexus,
hemorrhoidal plexus, and perlumbilical plexus.
13. Inferior lung border is in the 6th ics. Anteriorly, 8th ics laterally, and 10th ics posteriorly.
14. Deep and long respiration caused by severe metabolic acidosis is called kussmaul’s
respiration.
15. The percussion note of normal lung is resonance.
16. The normal extent of movement of inferior lung margin is 6-8 cm.
17. Techniques used in physical examination include inspection, palpation, percussion, and
asculatation.
18. To get the history of abdominal pain, use the letter PQRST to outline the pain characterisctics:
onset, precipitation factor, quality of pain, radiation of pain, severity of pain and timing.
19. Reduced movements of the abdominal wall indicate peritonitis, pep tine wall peritionitis.
20. Generalized abdominal distention may result from fluid, fat, and flatus.
21. The method of liver palpation includes single hand, alternative, bi-manual.
22. The mechanism of cardiac murmur are inc rate or vol of blood flow, dec. in diameter of heart
valve, valvular insufficiency.
23. When a trill could be palpable in the left 2nd parasternal area in the systole, it indicates the
patient with arterial septal defect / pulmonary stenosis.
24. Rapid assessment to a patient with abdominal pain determine whether the pain is emergent or
non-emergent.
25. Vital sign include temperature, blood pressure, pulse, respiratory.
26. The common cause of hemoptysis are bronchiectasis, lung cancer, CVC disease, and
pulmonary edema.
27. The most common causes of fever are infections by various infectious agents bacteria, virus,
fungi.
28. Review of systems involve organ system questions, history taking, physical examination.
29. Classification of jaundice depending on etiology include hemolytic jaundice, hepatocellular
jaundice, cholestatic jaundice and congenital jaundice.
30. The characteristics involving leads in AMI of interior wall ___________________________
lead - ____________________________ lead and ___________________________ lead.
31. AV conduction block was classified as 1st, 2nd, and 3rd (complete) degrees.
32. A lower first cardiac sound maybe caused by illness of myocardium, for example the patients
with myocardial infarction, myocarditis and myocardiopathy, and heart failure.
33. In individuals there may be four cardiac sounds. They are S1 (first heart sound), S2 (second
heart sound), S3 (third heart sound), and S4 (fourth heart sound).
34. The first heart sound is mainly related to the closure of both mitral valve and tricuspid valve.
35. In ECG, the P wave represents depolarization of the atrium, the P-R interval is the
summation of the periods of atrial depolarization and delay from AV node, the QRS
represents depolarization of the ventricles, the T wave represents ventricular repolarization.
36. In the ECG below the performed with a paper speed of 25 mm/s, the P-R interval is 16
seconds, the period of atrial is 12 seconds, the QT intervals is 36 seconds, the amplitude of
the P wave is 1 mv, the heart rate of the patients is about 68 beats per minute.
37. Chief complaints is main symptoms ÷ duration time.
38. Occult blood stool indicates the bleeding of < 5 ml, when hematochezia is caused by an
upper GI source, it indicates GI bleeding below ligament of treaty.
39. Edema is divided into 2 types, one is pitting edema, the other is non-pitting edema.
40. The four quadrants system is divide abdomen into 4 following sections: RUQ, RLQ, LUQ,
LLQ.
41. Along the right midclavicular line, the upper border of liver is found by percussion at ______.
Lower border extends down to right subcostal margin.
42. The cardiac auscultatory valve areas include mitral, pulmonary, 1st aortic, 2nd aortic, tricuspid.
43. The pulmonary valve area locates 2nd left intercostals space.
44. The genesis of arrhythmia is reentry, inc automaticity, triggered automaticity.

Long Questions
1. How to distinguish between hemoptysis and hematemesis?
Hemoptysis Hematemesis
Coughed up and frothy Vomit without frothy
Produced by stimulating cough Produced by vomiting and nausea
Bright red Dark red or brown
Alkaline Acid
History of coughing Gastric, liver disease
Blood tinged sputum Tar stool
Mixed with sputum Mixed with food
Anemia variable Blood loss common
2. What should the accompanying symptoms be considered as to cough?
- Cough with fever. - Cough with hemoptysis.
- Cough with chest pain. - Cough with clubbed finger.
- Cough with dyspnea. - Cough with wheeze.

3. The physical sign of pneumothorax.

 Inspection: bulging thorax and intercostals space, respiration movement decrease.
 Palpation: decrease tactile fremitus.
 Percussion: tympany.
 Auscultation: absent breath sound.

4. How to percuss upper and lower border of the liver?

Upper: executed along the right mid-clavicular line, right midaxillary line and night scapular
line. The level of the shift from resonance downward into dullness is defined as upper border
of liver.
Lower: executed along the right mid-clavicular line or anterior midline. The level of the shift
from tympany upward into dullness is defined as lower border of the liver.

5. What are the ECG criteria for the diagnosis of atrial fibrillation?
Atrial fibrillation constitutes a grossly irregular rhythm or no regular rhythm rate.
 A rapid irregular undulant of baseline (fibrillation waves) occurs instead a P waves.
 The ventricular rate that is usually a grossly irregular is seen. When the patient is given
the digitalis, the ventricular rate will show.

6. Please make a differential diagnosis for cardiac edema and renal edema.
Cardiac edema Renal edema
Location Onset from the face, periorbital Onset from the lower part of the
areas body
Progression Progress quickly Progress slowly
Identity Soft and mobile Relatively solid, less mobile
Accompany Proteinuria,hypertension, impaired Signs of heart failure, cardiac
enlargment
Signs Renal function Venous distention, hypertomegaly

7. The physical sign of pulmonary emphysema.

 Inspection: barrel chest, diminished respiratory system.
 Palpation: diminished tootile fermitus.
 Percussion: hyperresonance.
 Auscultation: absent or diminished breath sounds.
8. What are the mechanisms of cardiac murmur?
 Increasing the velocity of blood flow, such as in hyperthyroidism, exercise, anemia, and
pregnancy.
 Valve or artery stenosis.
 Valce insufficiency (regurgitation).
 Abnormal shunt.
 Abnormal chambers.
 Sudden increase of major vessel diameter: turbulent flow  vortices  murmur.

9. What is the feature of left ventricular hyperthrophy in ECG?

 The voltage of the S wave in lead V1 plus the voltage of the R wave in lead V5 or V6
exceeds 35 mm (Sv1 + R v5 > 35 mm).
 High-voltage R wave in lead aVL (13 mm or more) may be present when the heart is
electrically horizontal. When the axis is vertical, lead aVF may show a tall R wave (> 20
mm) as part of a QR complex.
 Left ventricular strain pattern (inverted T waves in leads with a QR pattern) may be
present.

10. What should be asked when you make insquisition?

 Symptom dimensions: onset, precipitating, quality, radiation, severity, temporal.
 Contents and skill of inquiry:
- General data. - Personal history.
- Chief complaints. - Marital history.
- Present illness. - Menstrual history.
- Past history. - Childbearing history.
- System review. - Family history.

11. How to percuss shifting dullness.

 The examiner percusses the patient’s abdomen at the umbilicus level from the
midabdomen toward the patient’s left side.
 If the examiner finds the point where percussion sound of tympany changes into dullness,
the examiner should hold his pleximeter on that point, simultaneously, ask the patient to
turn on his right side and then continue to percuss the same point again.
 If the sound changes from dullness to tympany, it means that the dullness has been
shifted to a more dependent position. This implies that ascites is present.
 A volume of free fluid in the peritoneal cavity greater than 1000ml can be detected with
this method.
12. Describe the name and location of five auscultatory valve area.
 The mitral valve area: in the 5th left intercostal space, 1 or 2 cm medial to the mid
clavicular line or the apical impulse area particularly in pathological cases.
 The pulmonary valve area: in the second left intercostal space just lateral to the sternum.
 The (first) aortic valve area: located in the second right intercostal space just lateral to the
sternum.
 The second aortic valve area: in the 3rd or 4th left intercostal space lateral to the sternum.
 The tricuspid valve area: located at the left or right side of the junction of the xiphoid
process.

13. Please name the six limb leads and the positions of positive and negative electrodes
respective y.
 Bipolar leads: I, II, III.
- I: right arm -, left arm +
- II: right arm -, left leg +
- III: left arm -, left leg +
 Augment leads: aVR, aVL, aVF.
- aVR: right arm +, left arm and left leg together -.
- aVF: left leg +, right and left arm together -.
- aVL: left arm +, right arm and left leg together -.

14. What does orthopnea refer to? Describe its clinical value.
Refers to: Difficulty in breathing in the supine position relived by sitting up.
Clinical value:
 Reduce the degree of pulmonary congestion by pooling blood in the lower extremities
 Improve the diaphragmatic movement
 Increase vital capacity

15. Normal bilirubin metabolism.

16. Please write down the contents of present history.
 Onset and duration.
 Features of chief symptoms.
 Cause of illness and precipitating factors.
 Progression of illness.
 Accompanied symptoms.
 Previous treatment.
 General condition.

17. List the symptoms and signs of peptic ulcer perforation.

 Inspection: appear pale, sweating, absent respiratory movement, pyloric stenosis.
 Palpation: board like abdomen.
 Percussion: absent dull-note.

18. What are the signs and symptoms of pneumothorax, chornic bronchitis, pleural
effusion, atelectasis, asthma, consolidation (pneumonia/hemorrhage)?
Inspection Auscultation Palpation Percussion
Pneumothorax Bulging thorax and Dec. tactile Tympany Diminished or
intercostals space, fremitus absent breath
respiratory movement dec. sounds
Atelectasis Retraction of thorax and Diminished or Dullness Dullness
intercostals space, dec. absent
respiratory movement
Pleural Bulging thorax and Dec tactile Dullness
effusion intercostals space, fremitus
respiratory movement dec.
Asthma Sit upright, gross wheeze Diffused Dec. tactile hyperresonance
with cyanosis, severe bronchi, fremitus
expiratory dyspnea, prolonged
activity of the accessory expiration
muscles
Consolidation Late inspiratory Inc. over the Dull
crackles over involved area
the involved
area
Chronic Cyanosis Dec. breath
bronchietis sounds, bronchi,
moist rales
19. What is the differentiation between S1 and S2?
S1 S2
Pitch Low High
Intensity High Low
Quality Blunter Brisker
Duration Long Short
Interval S1-S2<S2 to next S1
Apical impulse Concomitant Post
Clear audible area Apex Base