MEDICAL HISTORY CHECK LIST

Junior Internship A.Y. 2013 – 2014

GENERAL DATA

1. Room/Bed # 9. Birth date 17. Provincial address

2. Hospital # 10. Birth place 18. Contact number
3. Admission # 11. Educational attainment 19. Date and time of admission
4. Attending Physician/s 12. Civil status 20. Date and time of interview
5. Resident/s-in-Charge 13. Nationality 21. Informant
6. Name 14. Religion 22. Reliability
7. Age 15. Occupation
8. Sex 16. Current address

CHIEF COMPLAINT • Menstrual flow

− Interval
• Why did the patient seek care? − Duration
− Amount
HISTORY OF PRESENT ILLNESS − LMP
− PMP
1. Complete description of first symptoms 7. Marital and sexual history
• Provokes – causative, relieving, exacerbating • Obstetrical history/score
factors − Gravidity
• Quality − Parity
− Pain: sharp, dull, stabbing, burning, − Term
crushing − Preterm
• Radiates − Abortion
− Primary location − Living
− Area where it radiates • Family planning method/s
− Localization
• Severity (0 – 10)/Intensity/Progression PERSONAL AND SOCIAL HISTORY
• Time 1. Diet
− Onset 2. Habits
− Duration • Smoking history
− Persistence • Alcohol
− Number of occurences • Substance use/abuse
2. Medications (include dosage) 3. Hobbies
3. Results of previous laboratory work-up 4. Nutrition – diet and source of water
4. Results of previous ancillary procedures 5. Sleep pattern
5. State of health just before onset of problem 6. Exercise
• When did you last feel well? 7. Living arrangement
6. What led the patient to seek consult? 8. Source of income
9. Support system
PAST MEDICAL HISTORY 10. Employment and satisfaction
1. Childhood illnesses 11. Significant life events
2. Major adult illnesses
3. Medications ENVIRONMENTAL EXPOSURE
4. Previous hospital admission 1. Recent travel
5. Previous surgery 2. Tobacco
6. Menstrual history 3. Tattoos
• Menarche age 4. Sexual history
• Menopause age
INTERPERSONAL RELATIONSHIP
1. Family
2. Spouse
3. Peer group
DISEASE PREVENTION MEASURES 3. EARS
1. Immunizations • Hearing (pandinig)
• Diphtheria • Pain (pananakit)
• Pertussis • Dizziness (pagkahilo)
• Tetanus • Discharges (kakaibang lumalabas)
• Polio • Tinnitus (kakaibang naririnig)
• Hepatitis 4. NOSE
• Measles • Pain (pananakit)
• Mumps • Difficulty breathing (hirap sa paghinga)
• Rubella • Cold/flu (sinisipon)
• Influenza • Pain on sinuses (pananakit sa mukha)
• Others • Epistaxis (dumudugo ang ilong)
2. Regular medical visits • Discharges (kakaibang lumalabas)
3. Regular blood test/X-rays 5. MOUTH
• Results • Pain/ Sore tongue (pananakit)
• Lesions (sugat)
PAST MEDICAL HISTORY • Bleeding gums (dumudugo ang gilagid)
1. Allergies • Change of taste (nagiba ang panlasa)
2. Illnesses 6. THROAT
3. Operations • Sore throat (nangangati ang lalamunan)
4. Transfusions • Cough (inuubo)
5. Injuries • Phlegm (plema)
6. Medications • Trouble speaking (nahihirapan magsalita)
• Current 7. CHEST
• Frequently • Pain (pananakit)
• Herbal • Lumps (bukol)
7. Adverse drug reactions • Discharge from the breast (kakaibang
lumalabas mula sa suso)
FAMILY HISTORY 8. RESPIRATORY
1. Allergy • Dyspnea (hirap sa paghinga)
2. Asthma • Orthopnea (paggamit ng dalawang unan
3. Tuberculosis kapag natutulog)
4. Gout/Other arthritides • Hemoptysis (umubo at dumura ng dugo)
5. Blood dyscrasias • Paroxysmal nocturnal dyspnea (nagi-gising sa
6. Cancer gabi dahil sa hirap huminga)
7. Diabetes mellitus 9. CARDIAC
8. Heart diseases • Pain (pananakit ng dibdib)
9. Hypertension • Palpitation (nararamdaman ang pagtibok ng
10. Stroke puso)
11. Mental illness • Edema (pamamanas)
12. Others 10. LYMPHATIC
• Lymphadenopathy (pamamaga/bukol sa
REVIEW OF SYSTEMS leeg o singit)
1. SKIN • Lymph node pain (masakit ang namamaga)
• Changes in skin, nails, hair 11. GASTROINTESTINAL
• Lesions • Pain (pananakit sa tiyan)
• Rashes (pamamantal) • Nausea (pagkahilo, nasusuka)
• Soreness (pamamaga) • Vomiting (pagsusuka)
• Lumps (bukol) • Anorexia (kawalan ng gana kumain)
• Itching (pangangati) • Dysphagia (nahihirapan lumunok)
2. EYES • Heartburn (pananakit ng dibdib)
• Visual acuity (paningin) • Excessive gas (hangin sa tiyan)
• Visual specks (dumi) • Dyspepsia (masamang pakiramdam kapag
• Flashing light (bumubugsong ilaw) busog)
• Pain (pananakit) • Bowel movements (gaano kadalas ang
• Itching (pangangati) pagdudumi)
 • Change in stool: (pababago sa dumi)
− Color (kulay)
− Quantity (dami)
− Consistency: solid or liquid
(buo o matubig)
• Hematochezia (dumi na may kasamang
mapulang dugo)
• Melena (dumi na kulay itim)
12. GENITOURINARY
• Problem in urination (problema sa pagihi)
• Changes in urine: (pagbabago sa ihi)
− Color (kulay)
− Quantity (dami)
− Frequency (kadalasan)
• Dysuria (masakit ang pagihi)
• Urinary retention (pakiramdam na puno ang
pantog kahit matapos umihi)
• Hesitancy (nahihirapan simulan ang ihi)
• Urinary incontinence (inboluntaryong naihi –
pagtawa, nabahing, o pagubo)
• Force of stream (humihina ang lakas ng
pagihi, pinipilit ang pagihi)
• Dribbling (tumutulo kahit tapos na umihi)
• Nocturia (nagigising ng madalas dahil
kailangang umihi)
• Flank pain (pananakit ng likod)
13. MUSCULOSKELETAL
• Difficulty in ambulation (nahihirapang
gumalaw, maglakad)
• Joint pain (pananakit ng kasukasuhan)
14. NEUROLOGIC
• Headache (pananakit ng ulo)
• Dizziness (pagkahilo)
• Impaired memory (nakakalimot)
• Loss of consciousness (nahimatay)
• Tingling sensation (kakaibang pakiramdam sa
isang parte ng katawan)
• Seizures (pangangatog)
• Hallucinations (nakakakita ng mga bagay na
hindi totoo)
• Sensory perversion (pagbabago sa paningin,
pandinig, pangamoy, panlasa)
15. HEMATOLOGIC
• Pallor (namumutla)
• Easy fatigability (madaling mapagod)
• Spontaneous bleeding (pagdugo)
16. ENDOCRINE
• Polyphagia (sumusobra ang pagkain)
• Polyuria (dumami ang pagihi)
• Heat intolerance (mabilis mainitan)
• Cold intolerance (mabilis lamigin)
 PHYSICAL EXAMINATION CHECK LIST
Junior Internship A.Y. 2013 – 2014

GENERAL SURVEY
• General appearance, posture (relaxed, rigid, restless), grooming
• Describe general state of health (well, acutely ill or chronically ill)
• Level of comfort
– Comfortable or in distress
– Distress: speaks in phrases, tripod, orthopnea, squatting
• Level of consciousness
– Conscious, sedated, drowsy
Glasgow Coma Scale
Eye opening 4 Spontaneous
3 To voice
2 To pain
1 None
Verbal 5 Oriented
4 Confused
3 Inappropriate
words
2 Incomprehensibl
e words
1 None
Motor response 6 Obeys
commands
Makes an accurate general survey 5 Localizes pain
and reports accordingly.
4 Withdraws
3 Abnormal flexion
2 Abnormal
extension
1 None
• Ambulatory status
– Ambulatory – Wheelchair/Stretcher-borne
– Ambulatory with assistance – Bedridden
• Body habitus
– Hyposthenic/ectomorphic
– Sthenic/mesomorphic
– Hypersthenic/endomorphic
• Facies
– Moon facies
– Stare of hyperthyroid
• Mood and affect
– Towards examiner: cooperative, guarded, suspicious, evasive,
hostile, seductive
– Predominant mood: neutral, anxious, fearful, elated, euphoric,
angry, depressed, irritable
– Affect: broad, restricted, labile; Intensity: blunted, flat, animated
– Appropriateness
• Orientation: time, place, and
Assesses patient’s orientation as to
person • Attention
time, place, and person; memory,
• Memory: immediate, recent, • Calculation
attention/calculation.
remote
• Altered sensorium
• Prominence of SCM
Notes for any evidence of respiratory • Central cyanosis
• Retractions
distress • Speaks in phrases
• Abdominal paradox
• Tripod position
VITAL SIGNS
Preparation
Measures palpatory BP correctly.
Reports findings.
Measures auscultatory BP correctly. If
elevated, measures BP on other arm
and leg. (Leg BP may just be stated).
Reports findings.
Palpates for the patient’s radial pulse
correctly. State the rate, rhythm, and
volume.
Assessment of orthostatic hypotension
Determines respiratory rate in a subtle
way. Describes and reports the rate
and pattern of breathing.
• Ask intake of caffeinated drinks, smoking, alcohol, illicit drugs,
antihypertensive meds, NSAIDs, and steroids. Note time amount of
last intake.
• Instruct to avoid smoking. Intake of caffeine should be 30 minutes
before taking of BP.
• Stay on the side of the extremity being measured.
• Use index and middle finger to palpate for radial artery.
• Proper measurement of sphygmomanometer
– Width = 40% of upper arm circumference (12 to 14 cm)
– Length = 80% of upper arm circumference
• Apply cuff 2.5 cm above the antecubital fossa.
• Ensure the center of the inflatable bladder of the BP cuff is over the
brachial artery.
• Wrap cuff snugly. Must be able to insert only 1 finger underneath the
cuff.
• With one hand: palpate the radial artery pulse.
With other hand: inflate the cuff rapidly and note when pulse
disappears.
• Reads BP on the manometer and states palpatory (systolic) BP.
• Deflate cuff.
• State that the same procedure will be done on the other side.
Same preparation as above, except:
• Use index and middle finger to palpate for brachial artery.
• With one hand, apply the bell of the stethoscope over the brachial
artery.
• Inflate the cuff rapidly 30 mmHg above the palpatory (systolic BP)
previously recorded.
• Slowly deflate the cup by 2 to 3 mmHg/second.
• State the reading on the manometer when the first Korotkoff sound
is heard as the auscultatory systolic BP.
• Continue to deflate slowly by 2 to 3 mmHg/second and note level
on the manometer when Korotkoff sound disappears as the diastolic
BP (phase 5).
• Classification of blood pressure:
Class Systolic Diastolic
Normal <120 <80
Prehypertension 120 – 139 80 – 89
Stage I Hypertension 140 – 159 90 – 99
Stage II Hypertension ≥ 160 ≥ 100
• State the same procedure will be done on the other side.
• Use index and middle fingers to palpate for radial artery pulse.
• Count pulse rate for one full minute.
• Note rhythm: regular or irregular. Note volume.
• State the same procedure will be done on the other side.
Compare BP and PR supine and upright. Orthostatic hypotension is
present if there is:
• > 20 mmHg decrease in SBP
• > 10 mmHg decrease in DBP
• > 15 bpm increase in PR
• Note number of rise/fall (cycles) of the vest for 1 full minute.
– Normal: regular and comfortable at a rate of 12 to 20 per minute.
– Bradypnea: < 12 breaths/minute vs. Tachypnea: > 20
breaths/minute
• Patterns:
– Sighing: frequently interspersed deeper breath
– Air trapping: increasing difficulty in getting breath out

Takes the temperature and reports
findings.
Measures BMI (height and weight will
be provided)
SKIN
Inspects entire skin surface using
penlight and ruler if necessary. States
skin color texture, moisture, primary
and secondary lesions.
Inspects and palpates the head and
scalp systematically and reports
findings.
HEENT
Inspects for position and alignment of
eyebrows, eyelids, eyes. Inspect for
abnormalities of conjunctivae and
sclera.
Tests pupils for reactivity to light, both
direct and consensual as well as
accommodation (CN II and III)
– Cheyne-Stokes: varying periods of increasing depth interspersed
with apnea
– Kussmaul: rapid, deep, labored
– Biot: irregularly interspersed periods of apnea in a disorganized
sequence of breaths
– Ataxic: significant disorganization with irregular and varying
depths of respiration.
Axillary temperature:
• Press the button.
• Place tip of thermometer underneath the axilla.
• Instruct patient to firmly keep the thermometer in place.
• Read and state the temperature indicated.
BMI = Weight in kilograms/(Height in meters)2
Underweight < 18.5 Obese I 30 – 34.9
Healthy 18.5 – 24.9 Obese II 35 – 39.9
Overweight 25 – 29.9 Obese > 40
III
• Color: note presence of discoloration.
• Note moisture, temperature, texture, turgor, and mobility.
• Note primary lesions:
– Flat, nonpalpable: macule or patch
– Elevated, palpable: papule, plaque, nodule, or tumor
– Fluid filled: vesicle, bullae, pustule
• Note secondary lesions:
– Loss of skin surface: erosion, ulcer, fissure
– With material on skin surface: crust or scale
– Others: lichenification, keloid, scar, atrophy, excoriation,
comedone, teleangiectasia
• Describe lesions as to size, shape, location, configuration, color,
blanching, texture, elevation, depression, pediculation, presence of
exudates, patter of distribution, or odor.
• Note hair color, quantity, distribution, and texture.
• Note presence of seborrhea or lesions.
• Eyebrows
– Note symmetry, loss/extraordinary hair growth, presence of
seborrhea
• Eyelids
– Note symmetry, matting or loss, crusting, redness, swelling
• Eyes
– Note position, alignment, symmetry, size, shape
• Conjunctivae and Sclera
– Instruct patient to look up.
– Pull down lower lid of each eye to expose inferior sclera and
conjunctiva.
– Using a penlight, inspect sclera and conjunctiva of upper eyeball
for color, vascularity, and swelling. Do the same for the other eye.
Direct and Consensual Test
• Instruct patient to look into distance and not to focus on the light.
• Illuminate both eyes with lest amount of light possible to discern
pupil size and shape.
• Shine bright light in each pupil from a point slightly lateral to the
patient’s line of vision.
• Direct: check for pupillary constriction in the eye that light is shined
into.
 • Consensual: check for pupillary constriction in the eye opposite the
one light is shined into.
Accommodation
• Instruct patient to look into distance and then at finger/test object
held 2 to 4 inches from bridge of patient’s nose.
• Check for pupillary constriction when changing focus from distance
to object held close.
• Darken the room.
• Set the opthalmoscope at correct setting.
• Instruct patient to fix eyes on a specific point in the distance and try
not to move eyes.
• Use opthalmoscope in right hand: looks through it with right eye to
examine patient’s right eye and later vice versa
• Shine beam into eye from a position approximately 12 inches from
patient and about 15 degrees lateral to patient’s line of vision.
Fundoscopy
• Note orange glow in pupil, red reflex from retina, and opacities
interrupting red reflex.
• Move closer to patient’s eye to examine, retina, optic disc, retinal
vessels, peripheral retina, and macular area.
• Describe disc margin, report cup/disk ratio, A:V ratio, absence or
presence of hemorrhages, exudates, cotton wool spots, copper
wiring, AV nicking
• Repeat steps for the other eye.
• Ask patient to occlude each ear one at a time with his/her finger.
Checks hearing acuity in each ear.
• Use ticking watch, whispered or spoken voice to assess hearing
(Whisper test or watch ticking)
acuity.
Rinne Test
• Place base of vibrating tuning fork against the patient’s mastoid
bone and ask the patient to tell you when the sound is no longer
heard.
• Time this interval of bone conduction with your watch, note number
of seconds.
• Quickly position the still vibrating tines 1 to 2 cm from the auditory
canal and again ask the patient to tell you when the sound is no
longer heard.
• Time this interval of air conduction with your watch, note number of
seconds
• Compare the number of seconds sound is heard by bone
conduction versus air conduction. Air conduction should be 2x as
long as bone conduction.
Weber Test
• Place base of vibrating tuning fork on the midline of the patient’s
Assessment of hearing loss
head.
• Ask patient if sound is heard equally in both ears or is better in one
ear (lateralization).
• Avoid giving patient a cue as to best response.
• Patient should hear sound equally in both ears.
• If lateralized, ask patient to identify which ear hears the sound
better.
– Repeat procedure while occluding one ear. Should be heard best
in the occluded ear.

Interpretation
 TEST EXPECTED CONDUCTIVE LOSS SENSORINEURAL LOSS
Weber No Lateralization to Lateralization to
lateralization affected ear better ear
Rinne Air 2x longer Bone longer than Air longer than bone
than bone air in affected ear but less than 2:1 in
affected ear

• Turn patient’s head to one side and downward to inspect auditory

Inspect and palpate external ear for
canal.
deformities, tenderness.
• Grasp top of pinna, pull upward and backward to straighten canal.
• Inspect for wax, discharge, foreign bodies, redness, and swelling.
• Inspect tympanic membrane for the following, note normal findings:
– Color: transluscent, pearly gray color
– Landmarks: umbo, handle of malleus, light reflex
Performs otoscopic exam properly
– Contour: slightly conical with concavity at the umbo
and report findings.
– Perforations: none
• Inspect tympanic membrane for motion to assess Eustachian tube
function.
• State the same procedure will be done for the other side.
• Visually inspect and palpate nose for deformity, symmetry,
Inspects nose structure, nostril inflammation.
patency, septum position, • Elevate tip of nose with neck hyperextended.
inflammation of nasal mucosa. • Bilaterally inspect nasal mucosa.
• Inspect nasal septum.
Palpates for tenderness of the frontal,
• Apply digital pressure with the thumb and index finger over the
ethmoid, and maxillary sinuses. If
bony brow sides of the nasal bone as well as cheekbone.
tender, do trans-illumination.
• Instruct patient to open mouth.
Inspects lips, gums, teeth, tongue, floor
• With tongue blade and penlight visually inspect hard and soft
of the mouth, and posterior pharynx.
palate, buccal mucosa, gingiva, teeth, and tongue.
NECK
Examines palpable lymph nodes at
occipital, pre and post auricular,
• Using pads of index and middle fingers, move skin over underlying
submandibular, submental, anterior or
tissue in rotary motion.
posterior cervical and supraclavicular
areas. Reports findings.
With patient swallowing, palpates
• Bimanually palpate thyroid by pushing gently to the right with the
thyroid tissue correctly for size,
index and middle fingers of the left hand. This will allow palpation of
symmetry, and consistency. (May
the right lobe. Ask patient to swallow and assess.
stand either in front of or behind the
• Repeat steps to examine the left lobe.
patient.
Assesses whether trachea is midline None
ANTERIOR THORAX, LUNGS
Describes configuration of the anterior
chest. Note for deformities of the
• Normal: AP < lateral chest diameter (½:1)
chest. Compare AP to lateral chest
diameter.
Identifies sternal angle of Louis and
None
counts the spaces anteriorly.
Palpation:
• Ask patient to cross arms over chest.
Assesses symmetry of lung expansion • Stand behind patient and place thumbs along the spinal processes
(inspection and palpation). at the level of the tenth rib with palms slightly in contact with
posterolateral surfaces.
• Watch thumbs diverge during quiet and deep breathing.

Palpates for any tenderness in the
chest wall and performs tactile fremiti.
Percusses anterior lung fields.
Auscultates anterior lung fields.
BACK, POSTERIOR THORAX, LUNGS
Inspects back, cervical, and lumbar spine. Palpate each vertebral process from cervical to sacral.
Identifies inferior angle of the scapula and counts interspaces posteriorly.
Palpates for any tenderness in posterior chest wall.
Tests tactile fremiti, compares one side with another, tests top to bottom (patient’s arms crossed in front)
Performs percussion properly. Compares the percussion notes of both hemithoraces from top to bottom
(patient’s arms crossed in front).
JUGULAR VENOUS PULSES AND CAROTID PULSATION
Inspects neck veins and identifies
highest undulation of the right internal
jugular vein and measures JVP at 30 or
45 degree angle.
Palpates for carotid artery pulse (one
at a time) and describes.
Auscultates for carotid artery bruit,
one at a time.
Tactile fremiti:
• Ask patient to cross arms over chest.
• Ask patient to recite “Tres, tres”
• Systematically palpate chest with ulnar aspect of hands
• Percuss from apex to base of the lungs.
• Percuss both sides
• Diaphragmatic excursion:
– Prepare tape and measuring tape.
– Ask patient to take a deep breath and hold it.
– Percuss along the scapular line until you locate the lower border,
the point marked by a change in note from resonance to dullness.
– Mark the point with tape. Allow patient to breathe, and then
repeat the procedure on the other side.
– Ask the patient to take several breaths, to exhale as much as
possible and then to hold.
– Percuss up from the marked point and make a mark at the
change from dullness to resonance. Remind patient to start
breathing. Repeat on the other side.
– Measure and record distance in centimeters.
– Normal = 3 to 5 or 6 cm
• Use diaphragm of stethoscope.
• Note: vesicular, bronchovesicular, broncho-tracheal
• Position patient properly
– Lay patient supine in bed and raise patient’s head slightly on a
pillow
– Raise head of the bed at about 30 to 45 degree angle
– Turn the patient’s head slightly towards the left, exposing the right
side of the neck
• Using a tangential white light over the right side of the patient’s
neck, identify the right internal vein pulsation.
• Identify the highest points of the right jugular venous pulsation.
• Measure the JVP.
– Identify the sternal angle of Louis by starting from suprasternal
notch and slide finger down until hump is felt.
– Place ruler graduated in centimeters vertically on top of the
sternal angle of Louis
– Extend another ruler horizontally from the highest point of the
jugular venous pulsation perpendicular to ruler on sternal angle.
– Note vertical distance in centimeters above the angle of Louis at
which the rulers intersect.
– State the JVP in centimeters.
Note:
• Amplitude: 0 = absent, +1 = diminished, +2 = normal, +3 = full,
increased, +4 = bounding
• Contour: normal = smooth, rounded, domed
• Upstroke and downstroke
• Heard at just above the medial end of the clavicle and anterior
margin of the sternocleidomastoid muscle
CARDIOVASCULAR
Inspects precordium and reports its
dynamicity (adynamic, dynamic,
hyperdynamic)
Palpates precordium and describes
apex beat (location, diameter,
amplitude, duration in relation to
systole)
Palpates for LV or RV heaves, LA lifts,
RA lifts, abnormal pulsations over 2nd
ISC RPSL, and thrills.
Auscultates heart in following areas:
mitral, tricuspid, pulmonic, aortic,
auscultatory valve areas using
diaphragm in an inching manner and
note character of S1 and S2 and high
pitch murmurs if any.
Shifts to bell and note for S3 and S4
and any low pitch murmurs
Valsalva Maneuver
Inspection
• At eye level, check for precordial bulging and visible pulsations on
the precordium.
Palpation
• Palpate apex beat by using tips of the right index and middle
fingers.
• Location:
– While palpating the apex beat, palpate for sternal angle of Louis
with other hand
– From sternal angle slide fingers laterally to the left intercostal
spaces and count what intercostal space the apex beat is
located.
– Use a graduated (centimeter) ruler: note how far away from the
left midclavicular line and from the mid sternal line is the apex
beat found.
• Diameter:
– Apply tips of the fingers directly on top of the apex beat and note
the number of fingers needed to cover the apex beat
• Amplitude:
– With fingertips, feel for the apex beat and note height of pulsation
of the apex beat whether normal or hyperdynamic
• Duration:
– While palpating the apex beat, auscultate for the first and second
heart sound and note duration of systole
– Note how much of systole does the apex beat occupy
– Normal: apex beat occupies only up to half of systole
• Heaves:
– Using heel of the right hand palpate for abnormally strong
pulsation (left ventricular heave) or over the area of the apex
beat
– Using the heel of the right hand palpate for abnormally strong
pulsation (right ventricular heave) over the left side of the lower
sternum
• Lifts:
– Using fingertips, palpate for abnormal pulsation over the 2nd ICS
RPSL for aortic artery dilation
– Using fingertips, palpate for abnormal pulsation over the 3rd and
4th ICS LPSL for left atrial lift
• Thrills:
– Using ball of the hand feel for fine vibratory sensations over the
different clinical valve areas
– Mitral valve: apex beat (5th ICS), LMCL
– Tricuspid valve: left lower sternum
– Pulmonic valve: 2nd ICS LPSL
– Aortic valve: 2nd ICS RPSL
• Apex: S1 > S2
• Base: S2 > S1
• Carvallo Sign
– Ask patient to inhale then auscultate at the tricuspid valve (left
lower sternum), note murmur
None
• Ask patient to lie supine.
• Ask patient to forcibly exhale while occluding nostrils and closing
mouth.
• Auscultate for:

ABDOMEN
Instructs patient to relax, bend knees
to relax abdomen if needed and
expose abdomen.
Inspect abdomen: skin, contour,
symmetry, pulsations, visible peristalsis,
umbilicus, hernias (umbilical, inguinal)
Auscultates abdomen: bowel sounds,
bruit if any (abdominal aorta, renal
arteries, iliac arteries), and friction rub
Percusses abdomen systematically in
all 4 quadrants
Percusses for liver dullness (determine
upper and lower border) and
measures liver span along R
midclavicular line
Percusses for splenic dullness over
Traube space in LAAL on deep
inspiration.
Systematically palpates the entire
abdomen first light then deep while
looking at the face of the patient.
Note any direct or rebound
tenderness and any masses and
describe if present.
Palpates and describes liver edge.
Bimanual palpation of the spleen.
– Systolic murmur of HCM (Hypertrophic cardiomyopathy; left side):
becomes louder
– Systolic murmur of MVP (Mitral valve prolapse; left side): becomes
longer and louder
• Unlike most murmurs which decrease in volume and duration, HCM
and MVP increase.
• After release of Valsalva maneuver, right-sided murmurs tend to
return to control intensity earlier than left-sided murmurs.
• Stays at the right side of the patient
• Drape patient appropriately – expose the abdomen from xiphoid
process to symphysis pubis.
• Skin: striae, scars, spider angioma, dilated veins
• Contour: flat, scaphoid, protruberant, rounded
• Symmetry
• Visible pulsations
• Visible peristalsis
• Umbilicus: flat or everted
• Hernias: umbilical or inguinal
• Use diaphragm
• Bowel sounds: absent, hypoactive, hyperactive, borborygmi
• Bruits
– Over epigastric area
– RUQ
– LUQ
– Costovertebral angles
– Liver
• Friction rub
• Note for areas of tympanism and dullness
• Percuss lightly at the RUQ starting at a level below the umbilicus
going upward toward the liver and note for area of dullness = lower
border
• Percuss from lung resonance down toward the liver dullness = upper
border
• Measure the vertical span of liver dullness at the MCL
• Normal liver span = 6 to 12 cm
• From the sternal angle of Louis count down to the left 6th ICS
• Begin percussing at the LAAL down to the 10th ICS
• Note presence of splenic dullness
• Warm hands before palpating.
• Palpate with fingers together, flat on the abdominal surface
• Palpate abdomen initially with a light then with a deep but gentle
dipping motion.
• Palpate all quadrants.
• Place right hand well below the lower border of the liver dullness
• Press hand gently in and up
• Ask patient to take a deep breath
• Feel the liver edge as it comes down to meet the palpating fingers
• Evaluate liver edge and surface: smooth, nodular, irregular,
enlarged
• Ask patient to assume right lateral decubitus position
• Place left hand around and press forward the left lower rib cage
• Press right hand below the left costal margin toward the spleen
• Ask patient to take a deep breath
• Feel the tip or edge of the spleen as it comes down to meet the
palpating fingertips

Bimanual palpation of the kidneys.
Checks for CVA tenderness.
Murphy’s Sign
Obsturator test/Iliopsoas sign
Interpretation:
Pain = Positive = Appendicitis
Shifting dullness or Fluid wave
Rectal examination
• Stay at the side of the kidney being palpated
• Place ipsilateral hand and displace kidney anteriorly
• Place contralateral hand just below and parallel to the 12th rib
• Lift ipsilateral hand to displace kidney anteriorly
• Place contralateral hand gently at the right/left upper quadrant,
lateral and parallel to the rectus muscle
• Ask patient to take a deep breath
• At peak inspiration, press contralateral hand deeply into the
right/left upper quadrant just below the costal margin and capture
kidney between two hands
• Palpate the kidney during expiration by slowly releasing the pressure
of the contralateral hand feeling for the kidney as it slides back into
its expiratory position.
None
• Place palpating fingers beneath the right costal arch just below the
hepatic margin
• Ask the patient to take a deep breath
• While patient is inhaling, press fingers deeply beneath the arch
• Interruption of inhalation = positive Murphy’s sign = Cholecystitis
(RUQ)
• Iliopsoas Sign
– Ask patient to lie supine
– Place hand over lower right thigh
– Ask patient to raise right leg, flexing at the hip, while examiner
pushes downward
• Obturator Sign
– Ask patient to lie supine then flex the right leg at the hip and knee
to 90 degrees
– Hold the leg just above the knee, grasp the ankle, and rotate the
leg laterally and medially
• Shifting Dullness
– After identifying borders between tympany and dullness have
patient lie on one side and again percuss for tympany and
dullness and mark the border
– In patient without ascites borders will remain relatively constant
– With ascites, border of dullness shifts to the dependent side
(approaches midline) as the fluid resettles with gravity
• Fluid Wave
– With patient supine ask him/her to press the edge of the hand
and forearm firmly along vertical midline of the abdomen
– Place examiner’s hands on each side of the abdomen and strike
one side sharply with fingertips
– Feel for impulse of a fluid wave with fingertips of other hand
• Explain procedure to patient
• Ask patient to assume left lateral decubitus position with left leg
stretched and right knee flexed
• Drape patient appropriately
• Inspect perianal area for skin tag, lesions, external hemorrhoids,
lumps, opening of fistula.
• Perform digital examination:
– Wear gloves on right hand and lubricate index finger
– Insert lubricated finger gently into the anal canal pointing toward
the umbilicus
– Note for anal sphincteric tone
– Palpate anus on 4 quadrants and note for: mass, tenderness,
internal hemorrhoids, prostate size, consistency, tenderness,
nodule, cervix, blood on examining finger
• Wipe perianal area after examination
NEUROLOGIC AND MUSCULOSKELETAL
Tests for motor coordination: finger to
nose test (full arm extension) or
alternate pronation/supination test
Tests for balance/equilibrium:
Romberg/Tandem gait test
Checks conjugate extra ocular
movements (CN III, IV, VI) moving
finger slowly to 6 cardinal fields of
gaze.
Examines trigeminal nerve functions:
sensation to face and muscles of
mastication
Checks muscles of facial expression
(CN VII)
Tests gag reflex and note elevation of
palate (CN IX and X)
Can raise shoulder against resistance
(CN XI)
Asks patient to stick out tongue and
note whether it is midline during
protrusion (CN XII)
Checks motor strength of upper and
lower extremities and compare L and
R sides including ROM
Checks sensory function of upper and
lower extremities and compare L and
R sides
Checks DTR: biceps, triceps, patellar,
Achilles
None
• Romberg Test
– Ask patient (with eyes open and then closed) to stand, feet
together and arms at the sides.
– Stand close, prepared to catch the patient if he/she starts to fall.
– Slightly swaying movement is expected but not to the extent that
there is danger of falling.
– Loss of balance = positive sign
• Tandem Gait Test
– Heal to toe walking
– Direct patient to touch the toe of one foot with the heel of the
other foot
– Have the patient walk a straight line, first forward then backward
with eyes open and arms at the sides
– Consistent contact of the heel and toe should occur though slight
swaying is expected
– Note any extension of the arms for balance, instability, tendency
to fall, or lateral staggering and reeling, shuffling, widely placed
feet, toe walking, foot flow, leg lag, scissoring, loss of arm swing
• Ask patient to watch examiner’s finger as it moves through the six
cardinal fields of gaze without moving his/her head or using his/her
eyes only
None
• Raise eyebrows
• Squeeze eyes shut
• Wrinkle the forehead
• Frown
• Smile
• Show teeth
• Purse lips to whistle
• Puff out cheeks
None
None
None
• Test strength against resistance∏
• Flexion/extension
• Abduction/adduction
• Internal/external rotation
• State that the same procedure will be done on the other side
• Dorsiflexion/Plantar flexion
• Inversion/Eversion
• Toe flexion/extension
None