Taibah University

College of Medical Rehabilitation Sciences

Respiratory Therapy Department
Patient Assessment Course (RT 244)

Clinical Examination
Dr. Naseer Ahmad
Dr. Samah
Taibah University
 Why do we take history from
the patient?
What would happen if we do not make a
diagnosis?
OR
if we made the wrong diagnosis?
1- Healthcare provider:
• Hand wash, Meet, greet, introduce yourself
• Explain each procedure to the patient before you
start
• Seek permission and consent of the patient
• Correct position of the examiner on the right
side of the patient
• Ask the patient to position themselves at 45
degrees (in cardiorespiratory examination) and
flat (in abdominal examination) and to cover
their chest with a blanket.
• Talk politely, quietly but ensure good
communication, which may be difficult with deaf
or elderly patients.
• sensitively, but adequately, expose the areas of
the body to be examined
• cover the rest of the patient with a blanket or
sheet to ensure that he or she does not become
cold.
• Avoid unnecessary exposure and embarrassment.
• A female patient will appreciate the opportunity
to replace her bra after her chest examination
and before you examine her abdomen.
• Ensure your hand is warm
2- the examination room:
• privacy is essential when you examine a patient.
• Pulling the curtains around the bed in a ward
obscures vision but not sound.
• The room should be warm and well lit.
• Subtle abnormalities of complexion such as mild
jaundice are easier to detect in natural light.
• The height of the examination couch or bed
should be adjustable, with a step to enable
patients to get on to it easily.
• An adjustable backrest is essential, particularly
for breathless patients who cannot lie flat.
• Collect together all the equipment you need
before starting the examination
3- the Relatives: • Equipment required for a full examination

• Tactfully ask relatives to leave the room before • Stethoscope

the physical examination. • Measuring tape
• Sometimes it is appropriate for a relative to • Sphygmomanometer
remain if the patient is very apprehensive, • Cotton wool
• if you need a translator or if the patient • Disposable Neurotips
requests it. Parents should always be present • Wooden spatula
when you examine children
• Thermometer
• For any intimate examination you should always • Pulse oximeter
offer a chaperone to prevent misunderstandings
and to provide support and encouragement for • Accurate weighing scales and a height-measuring
device (preferably a Harpenden stadiometer)
the patient)
• Disposable gloves, lubricant gel and a
• Record the chaperone's name and presence. If bronchoscope,laryngoscope may also be required
patients decline the offer, respect their wishes • Facilities for obtaining blood samples, urinalysis
and record this in the notes. and faecal occult blood testing should be
available
Glasgow coma scale using 3 parameters
• Decubitus is style adopted by the patient in the
bed.
• Attitude is style which patient prefer on sitting
or walking.
• A- Orthopnea:
*Def: Dyspnea on recumbency relieved by sitting up.
*Causes:
I- Cardiac: Left sided heart failure
II- Respiratory causes:
1- Bilateral apical lung disease, as in bullous disease
of the lung & progressive massive fibrosis. 2- Acute
severe asthma. 3- COPD. 4- Pulmonary veno-
occlusive disease.
III- Extrathoracic causes:
1. Tense ascites. 2. Huge organomegally.
Paroxysmal nocturnal dyspnea (PND):
• Special pattern of orthopnea for cardiac patients
which is called cardiac asthma. Patient is aroused
1-2 hours after sleep with, severe dyspnea – cold
sweating –cyanosis and frothy expectoration.
Patient sit up in bed grasping its side to fix
shoulder girdle for accessory muscles of
respiration, he may stand beside an open window
• B- Platypnea
* Def: Dyspnea while sitting improves on
recumbency (the opposite of orthopnea).
* Causes: Bilateral basal pulmonary disease so the
processes in a disease of lower lobes rather than the
upper.
- - Bilateral basal pneumonia.
- Multiple recurrent lower lobes pulmonary emboli.
- - Basal interstitial fibrosis.
C- Trepopnea
* Def: Inability of the patient to lie
supine or prone but prefer a lateral
decubitus position.
* Causes: unilateral lung diseases as
in:
• Collapse. • Destroyed lung. • Pleural
effusion.
• Lung abscess. • Pneumonia.
• D- Talepnea
Dyspnea on lateral decubitus. Causes:
Unilateral lung diseases as before.
• E-Professorial Attitude (Tripod
position)
Professorial attitude: Patient stands
supporting his extended arms on table.
Tripod position: Patient sitting and support
his extended arms on his thighs or chair
* Causes:
-Asthma. -COPD.
• F- Prayer attitude
• *Def: Patients prefer leaning forwards:
• *Causes:
• -Massive pericardial effusion.
• -Anterior mediastinal mass.
*Def: It is a relationship between
height and span in relation to age, sex
and race.
Height: from the head to heal.
Span: the distance between distal
phalanxes of middle finger in both
extended arm.
1) Over built: (height > span.)
*Causes:
•Racial and familial.
•1ry hypogonadism.
•Gigantism (acromegaly).
2) Under built:
*Def: Stunted growth i.e. short status in
which span > height.
*Causes:
• Constituanal familial.
• Congenital disorders:
- Congenital cyanotic heart diseases. -
Congenital bronchiectasis. - - Down
syndrome.
• Chronic illness in childhood and infancy.
- Cystic fibrosis. - Bronchial
asthma (bad control).
- Rheumatic heart diseases.
• Endocrinal disorder:
- Pituitary dwarfism (↓ Growth hormone)
>>> Dwarfism
• I. History
• • Hx of weight loss > 10%
of IBW within 6 months
• • Hx of anorexia.
• • Hx of vomiting and or
diarrhea.
II. Clinical
• 1) Manifestation of vitamins
deficiency
• 2) Lower limb edema: due to
hypoproteinemia.
3) Anthropometric measures:
• Skin fold: (fat indicator).
Triceps. Chest , Midaxillary, Sub-
scapular 1 inch.
Abdomen, Supra-illiac , Thigh,
Supra-pubic ½ inch.
IV. Functional assessment:
• Reduced maximal inspiratory and
expiratory pressure
• Anergy (no reaction) to skin
testing (tuberculin test).
• ABGs: CO2 ↑ in high
carbohydrate consumption.
4) Circumferences: III. Laboratory
• Waist to hip circumference Waist 1- Serum albumin: (half life 20 days) 3.5 –
circumference 5gm/dl
• Mid arm circumference. Neck circumference 2- Transferrin level: (half life 10 days).
5) Indices and Ratios 3- Thyroxin prealbumin: is more sensitive and
specific half life 2 days only.
• Body mass index (BMI): Usually 4- Creatinine –height index:
Used - Reflect skeletal muscle mass.
Weight (kg)/(height meter)2 Normally 5- Urine urea nitrogen (UUN):
24kg/m2
6- Multiparameters nutritional index it include:
• Ideal body weight (IBW):
• Serum albumin + Transferritin level + Triceps skin
Actual weight (kg) / ideal weight (kg) x 100 fold + Skin testing for delayed hypersensitivity.
Normally 100%. • Respiratory quotients = CO2 production / O2
• Weight to height ratio: consumption = 200ml / 250ml = 0.8.

Weight (kg)/height (cm) Normally 0.4 • 4 Kcalories expended for each liter of O2
consumption.
Malnutrition *Grading of obesity >>>>>
*Def: is a state of impaired
metabolism in which there is
qualitative defect in the caloric
intake >> marasmus and
kwashiorkor
Under Nutrition
*Def: Cachexia and body
wasting are the other side of
the coin.
Obesity
*Def: Excess of body fat which
lead to increase in weight.
 Complexion
Colours

Pallor Jaundice Cyanosis

*Def:
Clinically, jaundice occurs when
Yellowish discolouration of mucous bilirubin level is ≥ 3mg/dl.
membranes and skin.
(Normally it is 1mg/dl).
*Sites of detection:
1) Sclera: at the lower fornix ,remember that Types of jaundice:
,sclera per-se is not vascularized while
episelera is vascularized and it is the site at
which its high elastin content has high
affinity for circulating high level of - Lemon yellow >> Hemolytic
unconjugated bilirubin. Jaundice starts early
in the periphery of the sclera then proceed jaundice.
towards the center of the eye.
- Orange yellow >> Hepatocellular
2) Frenulum of the tongue or soft palate. jaundice.
3) Skin: Occurs late or with high level of
bilirubin. - Olive green >> Obstructive
jaundice.
*Def:
Reduced or absence of reddish
coloration of mucous membrane and
skin of the palm. which depends on: the
vascularity and thickness of an overlying
mucous or skin of the examined area.
Mechanism of pallor:
1) Haemoglobin (Anaemia) either loss of
blood or inefficient erythropoeisis.
2) Blood flow (low COP).
3) Thickness of mucous membrane
(oedema).
4) Pigment and thickness of the skin.
*Sites of detection:
1- Inner aspect of the lips
but not outer aspects as it
changable by cosmetics.
2- Buccal cavity and tongue.
3- Hands:
- Nail bed.
- Palm and palmar creases .,,,
white creases = less than 9gm
HB.
*Def: Sites of detection
Bluish discoloration of mucous membrane
and/or the skin due to presence of more
than 5gm % (/dL) of reduced hemoglobin
• -Under surface of the
tongue.
in capillary blood.
• - Periphery and tip of
the tongue.
*Mechanism and etiology of cyanosis: • - Lips.
1- Defective hemoglobin oxygenation. • - Lobule of the ear.
2- Decrease hemoglobin concentration . • - Tip of the nose.
3- Defect of O2 consumption. • - Nail bed.
4- Circulatory failure i.e defective
perfusion.
1) Central cyanosis: 2) Peripheral cyanosis:
Site: all body but best seen in: Site:
• Tongue (tip – periphery – under surface). • lobule of ear – Tip of the
Causes: nose – Nail bed.
1- Hypoxemic hypoxia:
• inspired FiO2 (high altitude).
Causes:
• Hypoventilation (respiratory center depression).
• Raynauds disease (peripheral
• Shunt (pneumonia – pulmonary oedema – A/V malformation).
vascular insufficiency).
• V/Q mismatch (COPD – pulmonary embolism).
• Diffusion defect (IPF).
• Local thrombus or embolism.
2- Histotoxic hypoxia. • Cold weather.
• Cyanide poisoning. • Stasis due to C.H.F.
• Affinity hypoxia.
(congestive heart failure) (↓
peripheral perfusion or ↓ O2
• Methemoglobinemia. extraction)
• Sulfhemoglobinemia.
• CO poisoning.
 Vital signs

Pulse (Heart Blood

rate) pressure

Respiratory
Temperature
rate
• Pulse is a wave of blood created by the
contraction of left ventricle. reflects the heart
beat
• Assessment: is commonly assessed by
palpation (feeling) The middle 3 fingertips are
used with moderate pressure for palpation of
all pulses except apical
1) Rate
• Normally: 60 – 100 beat per minute
(bpm).
• > 100 tachycardia.
• < 60 bradycardia.
• Relationship between pulse and respiratory
rate is (4 pulses for one breath).
• Relationship between pulse and temperature
is (increase one degree increases pulse by 10
per minute).
• 2) Rhythm
Sinus rhythm defined as equal beat to beat interval so
it is regular
•Irregular pulse may be one of the following.
a- Occasionally irregular: as extrasystole (dropped
beat).
b- Regular irregularity as in: Pulsus bigeminous or
trigemenius.
c- Irregular irregularities as in: Atrial fibrillation
(AF).
3) Special characters Normal pulse consists of:
- Ascending limb: (Anacrotic limb) caused by
distended vessel by blood flow.
- Notch: (Diacrotic notch).
- Descending limb (catacrotic limb) caused by
recoil of aorta.
• Abnormal character: e.g. Water hammer pulse
… hyperdynamic circulation
4)Force Maximal amount of pressure required
to occlude the radial pulsation. Force represents
the systolic blood pressure. The larger the force
required to make the pulsation absent the higher
the systolic blood pressure well be and vice
versa.
Technique: one hand is used as classically
palpating for radial pulsation the proximal finger
is used to press, and palpates by the middle
finger.
5)Tension Tension represents the diastolic
blood pressure.
The minimal amount of pressure that required
to feel the pulsation.
*For comment on both force and tension say,
average, high or low.
6)Volume It represents the pulse pressure. i.e
the difference between force and tension, Pulse
pressure: is the difference between the systolic
and diastolic pressure. it may be one of the
following:
- Big pulse volume (Bounding pulse) as
hyperdynamic circulation.
- Average volume. Small volume as in
(pulsus parvus).
7)Equality on both sides Pulse normally
equal on both sides. But it may be unequal as
regard the force volume and tension
whoever., rate, rhythm, characters are
inevitably equal.
8) State of arterial wall Normally the wall is
not palpable but what is palpable is a column
of blood in smoothly tubular contoured
vessel. Testing for arterial wall: Compress
brachial artery till the radial is occluded,
normally it is collapsed with no pulsation.
9) Pulse deficit - Which is a difference
between the pulsation palpated on radial
artery and pulsation auscultated on
pericardium. - Normally the difference
[deficit] is not more than 5 beats/minute. -
AF is a major cause of pulse deficit.
From above downwards:
1- Head and neck:
- Superficial temporal artery.
- Carotid artery (pulsation of
life).
2- Upper limb:
- Axillary artery.
- Brachial artery.
- Radial artery (better palpable
than ulnar).
- Ulnar artery.
3- Abdomen:
- Abdominal aorta in midline (at
epigastrium) in thin individuals.
4- Lower limb:
- Femoral artery >>>> mid
inguinal point.
- Popliteal artery >>>> popliteal
fossa.
- Dorsalis pedis artery >>>>
dorsum of the foot.
- Anterior tibial artery >>>>
medial malleolus.
- Posterior tibial artery >>>>
lateral malleolus.
Definition:
• It is the force exerted by the blood against the walls
of the arteries in which it is flowing.
• It is expressed in terms of millimeters of mercury
(mm of Hg).
Types:
• Systolic pressure is the maximum of the pressure
against the wall of the vessel following ventricular
contraction.
• Diastolic pressure is the minimum pressure of the
blood against the walls of the vessels following
closure of aortic valve (ventricular relaxation).
Pulse pressure:
is the difference between the systolic and diastolic
pressure
Mean blood pressure (MAP):
MAP = Diastole + 1/3 (systole – diastole)
Normally 75 – 105 mmHg in adults.
• Sites of measurement
• Upper arm (using brachial artery
(commonest)
• Thigh around popliteal artery
• Fore –arm using radial artery
• Leg using posterior tibial artery or dorsalis
pedis artery
*Methods for measuring blood pressure:
• Palpatory method:
• Only measure systolic blood pressure.
• 7-10mmHg less than true (inaccurate method).
• But it avoid auscultatory gap (in hypertensive
patients)
• Auscultatory method:
- Using stethoscope
• Combined palpation and auscultation is reliable and
accurate.in which one can avoid recording the diastole as falsely
systol (Systol – gap – diastole).
• Doppler ultrasound.
• Invasive blood pressure: by intra-arterial device.
 Types of sphygmomanometers
1- Mercury sphygmomanometer: It is the most
conventional form of blood pressure apparatus and is • Automatic digital
considered to be the golden standard. sphygmomanometer: It is the
most technologically advanced
It consists of manually inflatable cuffs that are sphygmomanometer.
attached to the mercury-infused tubes. The
advantage of this sphygmomanometer is that they can • It consists of an electronic
last for a lifetime, easy to use and there is no need of sensor to measure the blood
recalibration. Due to its toxic contents, it is banned in pressure and the readings are
some countries. displayed on the digital monitor.
2) Aneroid sphygmomanometer: Aneroid means
“without fluid” and in this instrument there is no use
• In order to measure the blood
of mercury. It consists of a stethoscope which is
pressure, the instrument measure
attached to the cuff which is further attached to a dial the fluctuations of arteries.
gauge with tubing. The instrument needs to be • These need to be checked using
recalibrated to avoid faulty readings.
mercury sphygmomanometer to
• Different types of aneroid sphygmomanometer : avoid inaccurate readings.
• Pocket-aneroid sphygmomanometer

• Palm aneroid sphygmomanometer

• Clock-style aneroid sphygmometer

 Types of sphygmomanometers

Automatic digital sphygmomanometer

Mercury sphygmomanometer

Aneroid sphygmomanometer
 Anatomy of a Sphygmomanometer

Bulb Cuff

Manometer Bladder Valve

*Korotkoff sounds (phases of blood pressure):
• Phase I: sudden sharp tapping sound (systole).
• Phase II: murmur like sound.
• Phase III: loud sharp sound (accentuated
murmur).
• Phase IV: sudden  of sound.
• Phase V: disappearance of sound (diastole).
it is the hotness or coldness of the body.
Normal body temperature using oral 370C or
98.6 0F.
Kinds of Temperature
1. Core Temperature
Is the temperature of internal organs and it
remains constant most of the time (37oc);
with range of 36.5-37.5oc. Is the
Temperature of the deep tissues of the body
Remains relatively constant measure
with thermometer
2. Surface Temperature:
is the temperature of the skin, subcutaneous
tissue & fat cells and it rises & falls in
response to the environment Ranges:
Celsius, Fahrenheit It doesn’t indicate
internal physiology.
Normal body temperature is 37 0C or 98.6 0F
Normal:
Oral temp 36.6 – 37.2ºC.
Rectal 0.5 more.
Axillary 0.5 less.
Body temperature may be abnormal due to:
Pyrexia, fever: a body temperature above the
normal ranges 380c – 410 c (100.4 – 105.8 0F)
Hyper pyrexia: a very high fever, such as 410
C > 42 0c leads to death Hypothermia: body
temperature between 34 0c – 35 0c, < 34 0c is
death
Variation of temp of about (0.6 – 1ºC) in:
- Stress and exercises ↑ temp.- Menstrual
cycle (↑ temp at the time of ovulation in mid
cycle). - Diurnal variation.- Temp ↓ during
sleep and early morning. - Temp ↑ afternoon.
 Types of thermometer
Digit
al
Ear

Glass Forehead

Mercury
Thermometer

Non-
contact Probe
Forehead Strips Infra-red
Digital Thermometers
Oral temperature
• Obtained by putting the thermometer under the
tongue.
• Leave 3 to 5 minutes in place
• Is the most common site for temp measurement
• Contraindication:
• unconscious patients, mentally ill
• infants and children
• patients with ulcer or sore of the mouth
• pts with persistent cough.
• Patients receiving oxygen
• Advantage – easy access & patient comfort
• Disadvantage It can lead to a false reading if a
person has taken hot or cold food/ drink by
mouth, & has smoked so we have to wait for at
least 10-15min, after meal or smoking.
Rectal temperature
• Obtained by inserting the
thermometer into the rectum or
anus.
• It gives reliable measurement &
reflects the core body
temperature.
• Hold the thermometer in place
for 3 to 5 minutes
• More accurate, most reliable, is >
0.650 c (1 0F) higher than the
oral temperature because few
factors can influence the reading
Disadvantages are: injure the
rectum - it needs privacy -it is
inappropriate for patients with
diarrhea - anal fissure. -Rectal or
perennial surgery -Fecal impaction -
Rectal infection - newborn infants
Axillary temperature
• it is safe and non-invasive
• Is recommended for infants and
children
• Is the route of choice in pt’s that
cannot have their temp measured
by other routes.
• Disadvantage:
• long time (5-10min.)
• less accurate as it is not close to
major vessels.
• Is considered the least accurate &
least reliable of all the sites
because the temp obtained using
this route can be influenced by a
number of factors e.g. bathing &
friction during cleaning
Tympanic temperature
• Placed in to the the outer ear canal.
• It reflects the core body temperature
• Is readily accessible and permits rapid
temp readings in pediatric , or
unconscious pts
• It is very fast method 1 to2 seconds.
• Disadvantages: –
• it may be uncomfortable involves risk
of injuring the membrane
• Presence of wax can affect the
reading.
• Right & left measurements may
differ.
Technique of exam: 2) Depth:
• Counting RR by calculating the outward • Depth may be one of the following:
abdominal expansions • Shallow breathing >> Small tidal volume
• while distracting the attention of the • Apnea >> No tidal volume
patient by doing procedure for palpating
the radial pulse to ensure absence of • Deep breathing >> Large tidal volume
voluntary act of breathing.
1) Rate: A-Shallow breathing (hypopnea) or
*Normally RR: 12 – 20 breath/min. (oligopnea) i.e. low tidal Volume is called
restrictive breath, in which the compliance is
*Tachypnea: when RR > 20 breath/min. reduced. Its dangerous breathing pattern as it
↓↓ effective alveolar ventilation. caused by ↑↑
RR > 30 is critical and indicating severity in: in elastic work of breathing as in:
• Pneumonia.
• Pneumonia
• Asthma.
• pulmonary oedema.
* Bradypnea: when RR < 12.
• Collapse
• IPF.
 Respiratory Rate
B-Apnea: 3) Rhythm:
• Def: cessation of airflow for at least 10 seconds it A- Chyne-stokes breathing:
may be central, obstructive or mixed. *Characters:
C-Deep breathing (hyperpnea). I.e large tidal • Is a special type of central apnea manifested
volume as cyclic changes in breathing with a
crescendo-decrescendo sequence separated
*Deep and slow in resistive work of breathing as in by central apneas
obstructive airway diseases as in COPD – asthma.
*Causes:
• Deep breathing pattern is called obstructive breath,
- Cerebral embolism.
in which the resistance is increased.
- Lactoacidosis and uremia.
*Deep and rapid (hyperventilation) = (Kussmual
respiration). - Heart failure.
- High altitude.
*Def: In rate and depth of respiration sufficient to
reduce PaCO2 while maintaining high PaO2. B- Gasping respiration:
*Causes: Respiratory causes: - Characterized by irregular-quick inspiration
followed by prolonged expiratory pause
- Asthma. - Pneumonia.- Embolism. caused by cerebral hypoxemia.
 Extremities

Colours Temperature Vital signs

Clubbing Tremors Edema

Signs of deep
venous
thrombosis (DVT)
Definition for clubbing:
Enlargements of soft parts of the terminal
phalanges with both longitudinal and transverse
curving of the nail.
Examination for clubbing:
- Examine the distal phalanx of fingers in a
tangential view so inspect the side of the finger while
you are raising it to the level of your eyes.
Criteria to establish presence of clubbing:
1- Loss of lovibonds angle: (straight angle)
Hyponychial angle , unguophalangeal angle are other
names for the same angle.
The angle between the base of the nail and its
surrounding skin which is normally 160 degree.(less
than 180 degree)
2- Presence of space between the distal phalanx
and pencil putted in a parallel position documents
obliteration of lovibond angle.
3- Schamorths sign :
Illustrates an absence of diamond shape window
which is normally present when the terminal
phalanges of paired digit are Juxta posed.
4- Abnormal phalangeal depth ratio :
In which the depth of the finger tip at the cuticle
(distal phalangeal depth) DPD is equal or greater
than IPD which is the inter phalangeal depth
measured at the level of distal inter phalangeal Joint.
Normally DPD / IPD = 0.9
In clubbing DPD /IPD ≥ 1
5- Ballotability of the nail bed :
Which is springy feeling when the skin just proximal
to the nail is compressed?
- Presence of ballottement at the base of the nail
which is done by holding the distal phalanx of the
patient between your thumb and index finger while
you are doing compression and pulling downward.
* First degree: Obliteration of the angle due to filling of nail bed.
* 2nd degree : ( parrot peak ): Angle <180 with increased longitudinal
curvature of nail which appear smooth and chinny.
- Swollen proximal part of distal phalanx.
* 3rd degree (Drum Stick Finger ) :
- Entire digit is swollen.
- Increase in Transverse curvature of the nail.
- Circumferentail deposition of tissue under nail.
• Hypertrophic pulmonary osteoarthropathy (HPO)
- It is named Marie Bamberger syndrome.
- There is clubbing with periosteal bone formation. Bone is deposited in the
distal end of long bone (humerous and ulna in upper limb and tibia and
fibula in lower limb).
HPO is diagnosed by :
Plain x-ray onion like lower ends .
Scintigraphy is conclusive.
- HPO is caused mainly by long standing suppurative syndrome and pleural
fibroma.
Schamroth’s sign or schamroth’s window
test.
Causes of clubbing
1- Plumonary causes:
- Suppurative lung diseases .
- Interstitial pulmonary fibrosis.
- Primary and secondary
bronchial carcinoma.
- Benign pleural fibroma ( benign
mesothelioma )
- Intra pulmonary A / V
malformation: which may be
Congenital
Traumatic
Hepatopulmonary
syndrome.
Def : Involuntary, purposeless rhythmic oscillation
of one or both hands due to alternate contraction
of muscle groups and their antagonists..
Types: a- Fine tremor :
• It is less evident than coarse tremors.
Movement is evident more in interphalangeal
and metacarpophalangal joints than wrist
Causes:
* Physiologic : Exersice – fatiuge – emotional stress
– senility.
* Special habits : Smoking ,,when smoking index is
high. Chronic alcoholic intake. Excessive caffeine
drink.
* Iatrogenic: B2 agonist especially trebutaline –
theophyillin.
* Thyrotoxicosis.
* Hypoxemia.
b- Coarse tremors :
More evident than fine. & Movement is
evident at wrist joint level more than
phalangeal joints.
Causes:
- Organ failure: Respiratory failure. Liver cell
F – Heart F
- Parkinsonism.
- Cerebellar ataxia.
Technique for provokating tremors:
- Advice your patient to outextend his
hands and observe the tremors.
- Dorsiflect your patient hand for a
seconds then suddenly leave it
unsupported and record the presence of
tremor.
- Unsupported tongue may be a site for
eliciting the tremors.
Def: Swelling of the lower limb due to ↑
interstitial fluid.
- Normally water constitutes 60% of the body
weight, distributed as follow: 66% >> intracellular.
33% >> extracellular: 75% >> interstitial. 25% >>
intravascular. If
the interstitial fluid is > 15% =
frank edema occurs.
Examination for oedema:
• Inspection: Swollen lower limb. Skin
overlying becomes shiny, stretched, loss of
hair, oozing of fluid.
• Palpation: Either pitting or pinching methods
are used. Start behind the medial malleolus
then go through the medial surface of the chin
of tibia then pinch the thigh and the lower
abdomen
Grades of edema:
- Grade I: ankle edema.
- Grade II: ankle + leg.
- Grade III: ankle + leg + thigh.
- Grade IV: ankle + leg + thigh + lower
abdomen.
Types of edema:
1- Pitting or soft edema:
when the skin overlying bone is
compressed for 1/2 minute >> pitting
occurs indicate subcutaneous fluid.
2- Non pitting or hard edema:
- -ve pitting test.
- Skin overlying is coars, rough and may
show pean d’orange appearance.
A) Bilateral: B) Unilateral:

- Cardiac diseases. Soft:

- Hepatic diseases. - Vascular insufficiency.
- Hemiplegia.
- Renal diseases.
- Inflammatory disease.
- Malnutrition.
- Hormonal induced. Hard:
- Filariasis.
- Idiopathic. - Traumatic.
- Chronic local infection
• https://www.youtube.com/channel/UCyG7qeIHTBGlJqNrBi-_1NA
• Clinical Examination Videos
• https://www.youtube.com/channel/UCkjnrEHQ8bQQmlfNdAQC_5w
• Geeky Medics
• https://www.youtube.com/channel/UCUqgkmGj16aRxmVlHnDdVbw
• Medzcool
• https://www.youtube.com/channel/UCZCxwkQ-bVzq6aNqzASMdeQ
• Clinical Skills Training
• https://www.youtube.com/watch?v=Y74Ii03tdio
• 19. Squawk - Lung Sounds Collection- Dr. Prodigious