An easy, won to study & un *, Physical Ex: Re-drawen and created by Haneen Al-Maghrabi Um AlQuraa University Medical college, Makkah, KSA some pictures inspirated and created by Publishing website LucciLugee Liyeung Marthad Al-Hendi Taibah University Medical college www.liyeung.com Madinah, KSA www.liyeung.com marthad.wordpress.comThis Edition contains the following examinations: Neurological ( lower limb ), Vascular, Breast & Axillary lymph nodes, and Ulcer which created & drawn by Haneen Al-Maghrabi Other examinations: Respiratory, Cardiovascular, Gastrointestinal and neuological (CN and Upper limb ) systems are created & drawn by Lucci Lugee Liyeung and you can find them at her website, or on the internetCardiovasalar Examination « Also look For : - oxygen Supplements = Obese or not I = Respiratory 1. Inspection distress ~ Consciousness eo Sternotomy : -vaive replacment Submowuary + malay ras ~ mitra! valve ie ® ira usually under Pectoral muscies , Infraclawcutar scay ~ Blood preséure swide = AR + Warrew = AS - Radial pulse 1 vate Bregetarity 3. radio -vadiol olelany = radio. Femoral ey, = Paviphral Pulse EndocarditisCarotid pulse -weuer palpate both Carotid. Ge - Imp. to tell about ia i aorta and LN function. NS Stemocteido. mastoi =a muscle @) level = vB: OF thyroid Cartilage - Rapid outward mov. ~one peok | H-B 1. character a Palpable Stow raising «AS / Conapéing : AR = Independent of 2. Volume + Increase | decrease respiration 3. Condition of vessel watt JVP 2. -Perpendiculay rulers to find out the level of the IVP From the sternal angie - S } Assumed 40 be medial to s Bom above scm ! Right atrium. (.>Sem From Gternal angle = RO failure) 2. Height = 2+ Character: a ~ Abdemendyagular veFlux + 7 - Inform the Patient First ¥ + Conon waves complete 9 : bck Press the abdomen For 15 Sec. © Gaink aes : Pim. HTH = IVP vise and Fall with in 2 sec. cleeseale ase Ole (x Fan = R.& failure). | Absent qume: AE2. falpation A) APex beat = most latlar andi ior Pein 2) Hight = medial to mid clawicular line , 5% Intercostal space. 2) Character: «Tapping = ms « Hyperdynamic = As Pressure overload : ForéePasl * Hypervolaemic = AR / MR Volume overload : ForceFul + displaced) midclavicalar Tine = /\ SE Se + eRe ag 3E Can't Reel , dun to detine with 7 ) sr tinge Start From anterior left decubitus / feet right side. Or axillery tine and move medially B) Parasternal Heave = Place your Palm on the left side of the Sternum (move it up and doom). = In: -Pulmonary HT» ~ Right ventricie Hypertrophy / dilatation. hon = Palpablé murmer @) apex / parasternal / @ base when present , murmur > Grade 4Source: ¥ canvas +o my Inspirations by Lucel Lagee Liyeung Done by: 3. Auscultation laneen : Al-saghrabt A Wi ag aQqag i ee ® a © Axina @ T-area 2 e. oP bet @ lalar positon pie ss cele CR) 6 + 8 q 10 y y, ° \ ° 0 {| SEG | @ P-orta lean Forward , Bace of @ h-area ben @ necke (AR) _ then (AR 18) Exhale , hord breath oe “a Deon ae (ary Gracles (cH) © Describing Findings = 1D Heart Sound : 8, + 8, 2) Murmur: 2) Phase 2) Best heard @... 3) maneuver tot 4) Radiation §)Thril ( tue % grade 4 A “ve < grade 3) 3) other added Sounds. x don?t Forget to auscultare with ( Respiration » vaisalva maneuver , hand grip) 4) complete your Exaw + ~ Gack souscattate the base of tung (crbckes in HE) = Abclomen : Hepatomey.aly , splenomegaly , Ascites ~ lower limbs , edema, pvtRespiratory Examination 1. Ingpection «pallor Horner's Syndrome (constricted pupil? FaSial plethora (Smoker /$0¢0) a 2 verent™ swarm , Sweaty —— -Flapping wan | cyanosis * bounding Pulse . Clubbing + Osteotrophicarthropathy wasting muscle (Small one). Pariphral pulse. swalk 40 End of the bed, check « +. chest Expanssion a. respiratory vate (0-20) min)- Stars (atlar , under breast). + barrel chest - respiratory (astnma, Emphasema) 4 ~ ankle 4 vhythen + Pectus camiatum) otdema atu . 2.Cewital 'gmph wodes 1. Submental a. Submandibular 3. PreauriGular 4. PostauriCular 8. Jugular Chain 6. Supractavicular 1. posterior triamgle 8. Occipital (Always palpate From back , Normally nen- palpable) - ASK Patient to Shrug Shoulders. Feel by pressing deeply.3. Palpation ©) chest Expansion @) Trachea 0 Slightly ad ar. — Flexed cS eS ee neck sy “Re + Index and Fall OF 4h “End of ihe a leasi Cen e “s (Repeat at the Back) = middle Finger Ch sets, - = behind Supragtemnal ¢ Stance notch va eae ee => Palpate trachea deviation we “middle From the middle line chest” \ ree « lower ae chest™ b) Apex beat =To determine the mediastinal shit ‘of the lower mediastinum = displaced in hyperinflated chest 4, Percussion A eC @ Peccuss —y davical Cardiae . datiness \ liver iv duiiness 1. Anterior Compare left and right lung @ each tevel \ ae Lal Done in both Full Expiration ‘and fait Inspivattony, Cross the arms #2 avoid the Scapalot 3. Posterior Start at the midline toorder of the Scapula4+. Auscultation : Breath Sound Breath in through the mouth deeply and Slowly ¢compair Jefe and right): VY bell: tung apices Diaphragm» vest of tung Ji\\ ay hans 'e when crackles are hearel = nese aude cough and auscultate again dutiness* = Clear Partially : Bronchiactasts 1 Breath Sound : vesicular / Bronchial - N° changes + Fibrosis _ {and ‘inten sing) hiv €nkry (Symern eretical /* finy Added sounds: (wheede | stridor | crack les) . Bay ae £ B (Resonance) ( ( 5.Vacal Resonance i: Fremitis (Fremitis) (along the Same path aS auscultation). Source «canvas to my trspivations, by lcci tuges Liyeung Done by: Hancen Al. maghrabiGI. Examination 1. Inspection = Hepatic Flap Eye Pallor Jaundice Palmar Frvotid gland Erythema Sweiting Oupuiytren's Glossitis Contracture oath { Cyanosis ae Dehydration Sean oon > Spider naeut —_ Bruises eae A leuconychia. Axillary hair loos @ Serateh marks—~ Heparin block / tv-infusion Abdominal distension Scars | Stria G@ynaecomastia needles | Punctures Tubes and = — clvain$ Expansile pulsation (aortic aneursm) —_ Abnormal masses stoma Diteted veins wACaput medusae) "foun ambiieas Ankle \ Oecktusa. Expose groin and aSx the patient to Cough (cough Impulse) 3 Ke the Patient Flat on one Pillow, hands on the Sides. ae Proper exposure « From the nipple to the mid thign [top of Pubic hair a Tngpect the Abdomen from the end of the bed , ask the Patient 10 fake a deep breath.2. Palpation taht: Fatpeion =Flex MP joints Jeok at the Patient = Feel with Pulp of Ringers face (clues for = 100K Fors el deroess) XS “Tenderness - rebound tend. > 1-2 a make your hand ~ guarding warm | Palpate ail the uadrants in hun star from paint Deep palpation area. + organomeyaly SS + deep seated masses rms at the otf a mass is Felt ,ask the Pt to Pile the Flex his /her neck , jook at the lommen- abdem \ . ‘edomen comet's test). Kinet dousn i + disappear mass ¥ infra -abd. \ still the C mess "sin Semen Se eae mae 3 «liver Percusston Palpation polpatioy 4. Spleen suagel + poredsgres, it Ws pl O—»> thats A/S’ _ExXamination. wikis peweussion js pecthve ‘How to Examine the Spleen . 1 Gen: - Patient’s upper body uncovered (cover women’s breast witha folded towel). Legs should be covered till symphysis pubis (groin exposed). ~ Stand on patient’s right, Inspection: Supine pt. Look for fullness in the LUQ. Vots eppee 4 Q@Prereussion: 3 methods 2 Spe 90% Nixon’s method: P seus 2% guacvent > tot, Comal mar) fal point and percist along a line, perpendicular to left eas fr ore hen Sn, ens cle ‘83 7-Castell’s Method: agg Fine) fbae aoa ones id Pereussin expiration and fall nian BS Nomalyo duliess bt iyo bl ules oi appears n fl nation, it isabnormal in wit ef am sigh ace main tal margin, © ib superiorly andie mid anliany Perea at diferent levels nthe space, ging med to lat. Patient breathes normally 58% FY Traube's space: (Si seus 62%, ‘Ni: resonant @prtpation: 3methods Clow seus 27H, epee IS%). 2 hand method: Pt, Rt decubitus position ‘examiner's left hand is kept on the patient, flat on the left lower costal ‘margin, going from front to back, try to lift the lower rib cage ant and med. Ask patient o breath deeply. With the tps of the rt. Hand fingers, geally press just underneath the It Left costal margin, ‘Ef don't feel anything, lower the rt. Hand by 2.cm towards umbilicus and repeat the procedure. One hand method: patient supine 'No pressure applied tothe rib cage. Otherwise identical tothe 2-hand approach. Hook method: Supine ‘Keeps a fist under his If Costovertebral angle Stand on pt’s left, facing his leg With fingers of both hand, make a hook and curl under pt’s let lower costal ‘margin and ask him to breath deeply. ‘Never able to feel the upper border of spleen. Normally spleen lies ‘Measure 12 cm in length and Tem in width ‘Normal dullness is felt betwieen 9-11 ribs while pti in st decub Innormal asymptomatic individuals, with pretest probability of 10% or less, routine exam can not x/I or r/o splenomegaly. If pretest 10% or more, stat with percussion: + if percussion neg, no need to palpate (not sens or specific). If suspicion remains high, go for US.