EXAMINATION

MEDICINE

GENERAL SYSTEMS CHAPTER

1 DR. MOHCEN AL. HAJ

 GENERAL EXAMINATION

INTRODUCE YOUR SELF,, STAND ON THE RIGHT SIDE OF THE PATIENT &
TAKE PERMISSION FROM THE PATIENT FOR EXAMINATION.
.. ‫ أني (فالن فالن) طالب سنة خامسة في كلية الطب البشري‬.. ‫ صباح الخير يا حاج‬.. ‫السالم عليكم‬
... ‫ لو سمحت يا حاج من بعد إذنك وسامحني كثرت عليك‬.. ‫من بعد إذنك يا حاج نبي انديرلك كشف عام‬

1 GENERAL LOOK:

ABC / PM / SS
A: Appearance  The Patient is Well OR Ill.
B: Built  Average Weight OR Under Weight.
C: Color of Skin  Pale OR Yellow OR Plethoric.
P: Position  Laying Flat OR Sitting On Bed.
M: Mental State  Oriented OR Confused.
S: Surrounding  Has Canula OR Any Face Mask (Poly, Venturi, Nebulizer).
S: Spot Diagnosis  Large Face  Acromegaly, Bulging Eyes  Thyrotoxicosis.

2 HAIR SCALP LOOK:

Look at the Scalp For Any Hair Loss & Discoid Lupus FOR  SLE.

Medical Causes of Hair Loss:

1. Systemic Lupus Erythromatusus (SLE).
2. Scleroderma.
3. Endocrine Disease:
Hyperthyroidism, Hypothyroidism, Hypopituitarism.
4. Drugs:
Chemotherapy, Immune-Suppressant Drugs, Cytotoxic Drugs.
5. Malnutrition
6. Stress.

2 DR. MOHCEN AL. HAJ

 3 EYE BROW LOOK:

Look at the Eye Brows For Loss of Lateral Third Mainly Due to  Hypothyroidism.

Differential Diagnosis of Loss of lateral Third of Eye Brow:

1. Hypothyroidism.
2. Atopic Diseases.
3. Lepromatous Leprosy.
4. Herpes Zoster.
5. Trauma.

4 EYE LOOK:

Look at Conjunctiva If It Was Pale FOR  Anemia.

Look at Sclera If It Was Yellowish FOR  Jaundice (By Day Light).

Look Around Eyes FOR  Xanthelasma (Hypercholeselorenemia).

3 DR. MOHCEN AL. HAJ

 5 MOUTH LOOK:

Use Torch & Tongue Depressor.

Look at Lips For Any Ulcer, Cyanosis, Pigmentation & Angular Stomatitis.
Then Ask the Patient to Open His Mouth and:
Look at the Inner Surface of the Lips For Any Ulcers.

Look at the Tongue If There is Any Smoothness FOR  Anemia.

Look at the Gum & Dental Hygiene and Ask If There is Any Artificial Teeth.

4 DR. MOHCEN AL. HAJ

 6 GENERAL FACE LOOK:

Greasy & Mask Face FOR  Parkinsonism.

Peaked Nose, Small Mouth & Tight Shiny Skin FOR  Systemic Sclerosis.

Face Rash (Malar OR Butterfly Rash) FOR  SLE & Mitral Stenosis.

Differential Diagnosis of Malar Rash:

1. Systemic Lupus Erythromatusus (SLE).
2. Mitral Stenosis.
3. Hypothyroidism.
4. Rosacea.

5 DR. MOHCEN AL. HAJ

 7 NECK EXAMINATION:

Inspection:

Look FOR: S.S.D

Scar (Collar Scar)  Indicate Thyroidectomy.

Swelling  Indicate Lymphadenopathy, Goiter, Thyroglossal Cyst.

Dilated Veins  Engorged Neck Veins Indicate SVC Obstruction.

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 Palpation:

 Palpate Lymph Nodes Which are:

Stand Behind the Patient Stand in Front of the Patient

and Palpate: and Palpate:
Sub-Mental LN; By Tip of Fingers & Comment On:
Size, Tenderness, Consistency, Mobile OR Not. Posterior Cervical LN; By Tip of Fingers &
Comment On: Size, Tenderness,
Sub-Mandibular LN; By Tip of Fingers & Comment Consistency, Mobile OR Not.
On: Size, Tenderness, Consistency, Mobile OR Not
Post-Auricular LN; By Tip of Fingers &
Pre-Auricular LN; By Tip of Fingers & Comment
Comment On: Size, Tenderness,
On: Size, Tenderness, Consistency, Mobile OR Not
Consistency, Mobile OR Not.
Anterior Cervical LN; By Tip of Fingers &Comment
On: Size, Tenderness, Consistency, Mobile OR Not Occipital LN; By Tip of Fingers & Comment
On: Size, Tenderness, Consistency, Mobile
Supra-Clavicular LN; Ask Patient to Elevate His OR Not.
Shoulders Then Use Tip of Fingers & Comment On:
Size, Tenderness, Consistency, Mobile OR Not.

7 DR. MOHCEN AL. HAJ

  Palpate Thyroid:
Stand Behind the Patient & Place the Palm of Your Both Hands On Both Sides of the Neck as in the
Picture, and Use Tip of Your Fingers to Palpate Any Mass OR Swelling,
Palpate the Right Lobe of Thyroid Gland By Your Right Hand and Keep the left Hand Fixed On the
Left Lobe of Thyroid Gland, After That Palpate the Left Lobe of Thyroid Gland By Your Left Hand
and Keep the Right Hand Fixed On the Right Lobe of Thyroid Gland as in the Picture.

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 Palpate Trachea:
Stand in Front of The Patient & Put Your Index Finger On the Medial End of the Right Clavicle and
Put Your Ring Finger On the Medial End of the Left Clavicle as in the Picture,
Then Use Your Middle Finger and Try to Palpate the Trachea as in the Picture and Check If It
Centralized OR Not,
(Normally the Distance Between the Index Finger and Middle Finger is Equal to the Distance
Between Ring Finger and Middle Finger  Equi-Distance).

8 DR. MOHCEN AL. HAJ

 8 UPPER LIMB EXAMINATION:

First Ask Permission From the Examiner To Do Examination For Axillary Lymph Node and Say:
I Would Like to Examine Axillary Lymph Nodes.

Now Start Upper Limb Examination By The Following Steps:

1. Look at the Nail of Both Hands FOR:

 Clubbing; Indicate  Multi Systemic Diseases; (Cancer Lung, Broncheictesis, Lung Abscess,
Interstitial Lung Disease, Infective Endocarditis, Cyanotic Heart Disease, Celiac Disease,
Inflammatory Bowel Disease, Liver Cirrhosis, Hyperthyroidism).

If the Patient Has Clubbing; You Have to Do Window Sign to Test the Clubbing:

Ask the Patient To Face the Nail of Each Finger Infront of Nail of Each Finger in the Other Hand
as in the Picture; That Means:
Nail of Index Finger of Right Hand Facing Nail of Index Finger of the Left Hand,
and Nail of Middle Finger of Right Hand Facing Nail of Middle Finger of the Left Hand,
and Nail of Ring Finger of Right Hand Facing Nail of Ring Finger of the Left Hand,
and Nail of Little Finger of Right Hand Facing Nail of Little Finger of the Left Hand,
and Nail of Thumb of Right Hand Facing Nail of Thumb of the Left Hand,

Observes If there is Window In Between the Nails at the Nail Root OR Not,
Normally There is a Window In Between the Nails,
In Case of Clubbing; There is No Window.

9 DR. MOHCEN AL. HAJ

  Bluish Nail; Indicate Cyanosis.

 Half and Half Nail (Proximal White & Distal Brown); Indicate  Chronic Kidney Disease.

 White Nail (Leukonychia); Indicate  Hypoalbumenemia, Liver Cirhhosis.

 Spoon Shape Nail (Koilonychia); Indicate  Iron Deficiency Anemia.

 Splinter Heamorrhage; Indicate  SLE, Infective Endocarditis, Trauma.

Separation of Nail From Nail Bed (Onecholysis); Indicate Trauma, Psoriasis, Lichen Planus.

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 2. Look at The Dorsum of the Both Hands FOR:
Muscle Wasting OR Any Scars.

3. Look at The Palm of Both Hands FOR:

 Palmar Erythema; Indicate  Liver Cirrhosis, Thyrotoxicosis, Rheumatoid Arthritis,
Hypercapnia, Polycythemia & Pregnancy.

 Pallor of Palmar Creases; Indicate  Anemia.

 Muscle Wasting OR Any Scars  Carpal Tunnel Syndrome Decompression Surgery.

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 4. Look For Radial Artery Site For Pulse and You Have to Comment On:
Rate, Rhythm, Volume, Character, Synchronization & Radial Artery Wall.

 Rate: Normally 60-100 Beat Per Minute,

But Your Ring, Middle & Index Finger On Flexor Surface of the Wrist On Radial Border, and Try To
Feel the Pulse,
Then You Have to Count the Rate During Full One Minute, and You Have To Comment If it Was Normal
Rate (60-100), OR Tachycardia (as in Anxiety, Anemia, Fever, Thyrotoxicosis,& Pheochromocytoma),
OR Bradycardia (as in Athletics, Hypothermia, Hypothyroidism, Obstructive Jaundice & High ICP).

 Rhythm: Normally Regular Rhythm (Rhythmic),

While You are Putting Your Fingers Counting the Pulse, Try to Feel the Rhythm of Each Pulse and
Compare The Pulses with Each Other If They Were Regular and at the Same Pattern, and You Have
To Comment If it Was Rhythmic Pulse (Normally), OR Irregular Irregular Pulse (as in Atrial
Fibrillation & Ventricular Fibrillation), OR Regular Irregular Pulse (as in Digoxin Toxicity, Ventriclar
Tachycardia & Ventricular Ectopic).

 Volume: Normally Good Volume,

While You are Putting Your Fingers Counting the Pulse, Try to Feel the Volume of Each Pulse, and You
Have To Comment If It Was Good Volume (Normally), OR Large Volume (as in Anemia, Thyrotoxicosis,
Aortic Regurgitation & Pregnancy), OR Small Volume Pulse (as in Heart Failure, Aortic Stenosis &
Mitral Stenosis).

 Character: Special Characters:

Collapsing Pulse (Water Hummer Pulse):
1. First Ask the Patient If He Has Any Pain in His Upper Limbs.
2. Try To Localize the Pulse of Brachial Artery and Put Your Fingers There.
3. Use Your Other Hand To Catch the Wrist Joint By Your Fingers Above The Radial Artery.
4. Do Sudden Elevation of the Upper Limb.
5. If You Palpate Strong Pulse; That Means  Positive Collapsing Pulse (as in Aortic Regurgitation,
Anemia, Fever, Thyrotoxicosis & Pregnancy).

12 DR. MOHCEN AL. HAJ

 Other Types of Pulses:

*Pulsus Tardus (Slow Rising Pulse), Occur in Aortic Stenosis.

*Pulsus Paradoxus: Decrease of Blood Pressure More Than 10 mmHg During

Inspiration, Occur in Acute Sever Asthma, Pericardial Tamponade & Constrictive
Pericardtis.

*Pulsus Bisferiens: Double Systolic Pulsation Felt in Carotid, Occurs in Combined

Aortic Regurgitation & Aortic Stenosis at Same Time.

13 DR. MOHCEN AL. HAJ

  Synchronicity:
Synchronize Between Right and Left Radial Artery  Done By Compression On Right and Left Radial
Artery at the Same Time  Normally You Will Palpate the Two Pulses at the Same Time.

Synchronize Between Radial Artery and Femoral Artery  Done By Compression On Radial Artery and
Femoral Artery at the Same Time  Normally You Will Palpate the Two Pulses at the Same Time.
(Radio Femoral Delay Indicate Coarctation of Aorta).

 Radial Artery Wall:

Comment How You Feel the Wall of Radial Artery (Cord Like in Atherosclrosis).

14 DR. MOHCEN AL. HAJ

Ask the Permission From the Examiner and Say; I Would Like to Measure Blood Pressure;
[Look For Brachial Artery Site (Medial Aspect of Cubital Fossa) and Put Your Sphygmomanometer &
Your Stethoscope and Measure the Blood Pressure, Normally 120/80 – 139/89 mmHg].

Ask the Permission From the Examiner and Say; I Would Like to Measure the Temperature
[By Putting the Thermometer in the Axilla, Leave It for One Minute, Then When You Read It; Increase
Half Degree to the Reading, Normal Temperature 36.2 – 37.5C].

Ask the Permission From the Examiner and Say; I Would Like to Measure the Respiratory Rate
[By Counting Abdominal Movement During Full Minute, Normally 12-21 Cycle Per Minute].

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 9 LOWER LIMB EXAMINATION:

Inspection:

1. Stand at the End of the Bed to Observes Any Swelling and Redness; Check If It is Unilateral
OR Bilateral,
If There is Any Swelling; Use Your Tape Major to Confirm That.

2. Check the Veins Above Medial Malleulus and Popliteal Fossa For Any Superficial Dilated
Veins (Varicose Veins).

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3. Check the Calf Muscle of Both Limbs For Any Muscles Wasting; Confirmed By Tape Major.

4. Look For Any Ulcers OR Scars.

Palpation:

1. Check the Temperature of Lower Limb By Dorsum of Your Hand Starting Distally and
Compare It With Proximal Part, Then Compare Between Right and Left Lower Limb.

2. Ask the Patient If He Has Pain in His Limbs, Then Check If There is Any Tenderness in His
Calf Muscles.

3. If There is Lower Limb Swelling (Edema); You Have to Make Sure If It is Pitting or Non
Pitting By
Pressing with Your Thumb in the Junction Between Lower One Third and Upper Two Third of the
Leg, and Observe If there is Depression at Site of Your Thumb Pressure On Lower Limb.

4. Ask Permission From the Examiner To Do Examination For Inguinal Lymph Node and Say:
I Would Like to Examine Inguinal Lymph Nodes.

*Finally: Cover the Patient and Thank The Patient and Say  .. ‫ سامحني وان شاء هللا الباس عليك‬, ‫شكرا يا حاج‬

17 DR. MOHCEN AL. HAJ