Edited by: Dr. Dipendra Khadl MBBS (KU), MD (KU) Medicins ase taxincts +) Use Ta) wee ie (68) RATURE V4 4 a Ved a . at bration 198 c c Ly \(PH NODE EXAMINATION 196 c RAL EXAMINATION OF A NT ASS. RESPIRATOTY SYSTEM 44% CARDIOVASCULAR SYSTEM 8826 ABDOMINAL SYSTEM 02 98 GENITOURINARY SYSTEM 77°. NERVOUSSYSTEM 274 CHEST X-RAY 339. roc Boe REFERENCES: Hutehison's clinical methods Macleod's clinical examination Manual of Practical Medicine, R, Alagappan Davidson's Principles and Practice of Medicine Harrison's Principles of Internal Medicine Bedside Clinics in Medicine Part I, Arup Kumar Kundi Bedside Clinics in Medicine Part Il, Arup Kumar Kundu Medicine: Prep Manual for Undergraduates, K. George Mathews; Praveen Aggarwal ECG made easy, Atul Luthra The ECG made easy, John R. Hampton (Chest X-ray made easy BATES Guide to Physical Examination & History Taking, ‘Textbook of Human Neuroanatomy (Fundamental and Clinical), Inderbir Singh Clinical neuroanatomy, Richard S. Snell BD Chaurasia's Human Anatomy Volume 1, 2 and 3Particulars Chief complaints History of present illness “History of past illness Personal history Treatment history Socioeconomic history Drug and allergy history General examination’ Local examination Systemic examination Respiratory) Cardiovascular ‘Abdominal! Name; Identity; clue about country, state and religion. Needed for obtaining information from. CASE TAKING 2 Ischemic heart disease, Bronchogenic carcinoma Haemophilia nale: Autoimmune diseases like SLE Thyroid disorder ws/ Muslims (citcumeision); Less prone to CaPenis Muslims (co to decompensated liver disease Less prone to Ca lung Less Certain Hindus (cons prone to Ca colon Occupation: « Silicosis: Mine workers (@romatic amine) © Mesothelioma: Asbestos hours of standing) ‘Marital status h. Date of examination Chief Complaints: = Current complaint which brought patient to hospital & their duration in chronological order History of present illness: Elaborate patient complaints in their own words from its onset to its present state © No leading questionsSiar ilness nthe Past i afletier medic! o° UMMA saad disenses tt he Wont had suffered i: Hypertension Re Rheumatic fee" EE ‘a: Asthma, Aniety Arthritis patient Disease had to take medi g duration? pee Depression forlong How long? ; staking 5: Surgical history What type (Cigarette, Cigar or Pipe) Number of cigarette per day Duration of smoking in years Pack years = ‘Number of cigarettes smoked per day * ‘Duration of smoking in ‘Rskfor lang cancer=30 pack years American ‘Associaton for Thoracic Surgery) ‘Smoking index (S1)= Number of cigarettes smoked per day * ‘Duration of smoking in years 51 < 100 = mild smoker, 101 to 300 = moderate smoker, > 300 heavy smoker Lung cancers common if SI > 300, Alcohol 8 What type (Local, Wine, Whiskey, Beet) Daily/weekly pattern (specially binge Arinking and morning drinking) Usual place of drinking Alone or accompanied = Purpose Amount of money spent on alcohol * Attitude to alcohol 7 {alcohol deP' inquiry: . sor felt the need to Cut dwg, Enel consumption? aspiave you tlt Angry st otnetaag inking? Seen ever feel Guilty about extess ver drink in morning a8 Bye .nswer for problemof G:Doyou E:Doyou up 1 Know alcohol by volume SP cer 5%, Cider 4.5%, Winemy Champagne 12%, Spirit 40%) Ned Romy Gin 375%, Whisky 40%, Home 13% (NHRC 2015)isu roe cot] « traditional volumes: step 2: Know t I Tea glass 150 ml, Water glass 250 mi bottle 650 ml step 3: Number of units Volume * % of alcohol by volume: : 700 (since, 1 unit= 10 gram] regular consumption of more thang ceetbrmen and more than 2 uniter Tobacco betel nut chewing: More PRO ral cavity Food habit: Vep/ nomveg Bladder and bowel habits local f, Sleep and appetite g. lf femal ‘Ask: Menstrual history, Obstetric his Contraceptive history (As given | gynae section) Family history: "= Similar illness in any of the family met 1 Diseases (THREAD) like Diabetes, ‘which may be hereditary; = Recent exposure to i 8 dis Recent expa infectious Socioeconomic history: Occupation, Family income, Educa "Housing condition (Type of hous rooms, separate toilet, kitchen) Ventilation facility, Surrounding © Source of water Drug ind allergic history. 's the patient taking any drug at Any history of allerg Any history of allergies to any’ mi y ther things like some food) ust ial pulse 18 21 emitted along arte Miuring cardiac ¢) } t F volume | 1 Character) J Condition of Radio-radial d Radio-femoral Rhythm Palpation of p fal artery: P Bx0r Carpi Rary atothets crite silty about excess d ‘by volume onal volumes: 1, Water glass 250 mi nits alcohol by volume: 7000 10 gram} ion of more than 3 Uy nore than 2 unit per d hewing: More prone veg abits ry, Obstetric history, nistory (As given inv of the family mem ncome, Education Type of house, kitchen) srrounding sani ny drug at Pre jes to any med ‘ome food, dus pulse is a palpable pressure wave form Tong arterial Wall and generated at root of z cardiac cycle | ra ravthm J palpating radial artery volume | bestassessed by character! palpating carotid artery Condition of vessel wall adio-raial delay fadio-femoral delay palpation of peripheral arteries Posterior isla Racial artery: Palpated at the wrist, lateral to the Bésos Carpi Radialis tendon against lower border lth font of radius (radial styloid process) ® old the patient's wrist as if you are going to shake your hands (hold the patient's right hand With your right hand or viee versa) B Now slightly flex the wrist and assess Radial Pulse with3 fingers ipheralartr ee Distal finger: Fixes Middle finger: Feels ‘Assesses state of w Patpate both radial pulses simultaneously for Radio-radial delay Palpate the Radial and Femoral pulse simultaneously for Radio-femoral delay Check for the condition of arterial wall—ediion otvesew | [Comment Rate, uae | Radio-adial del | ecubital F852, atpated inthe atest "I rosie lowe! aa to bleps tendon: oP apne with eum wih 7 rack he elbow around the| vee eeainer mi ruPPoR REDS tbo wight le with ee thu \ eames ery; Palpated medial fo seid mscte atthe level Of MEPS eae ge gat cro ee c process of 6th ede of ere) of anes (Coase aera incaota ian | Soo ea unb i eenecedemast | Pa lotta tte! | Sly toward te a rend of sur finger cuPPed | nisrelaxed | ey emmpressing te bFachal | [Votume and charact palpating it | ses simultaneous! | Tempora avery: alpen ont | Sflne agus ofthe ear agaist zygomatic Bone. Gubelavin atery: Palpated just posterior tothe | ? idle third of clavicle by shrugging the shoulder (cgans the 1st). | Femoral artery Pal ‘ginal lig in the groin just below the Imidway between the anterior | | 10, Je and the pubic symphysis (mid | ®agrnst the head ofthe femur and the |] major. patient tolie supine with hip flexed about | puuse RATE: |2 Sep ia swith finger extended places palpate a fingers over the femora index and middle rea ife patente suey ‘cree Reed itmakes 135° co thumbs onthe tial Suber a aay fossa with 4 Fingers ofeach ett ane Pai a ec of upper endo HO Place Foptructive Fpaiced Intra cranial Press Byasovagal attack Dyicart blocks” gs: Beta blockers Vet palpate in prone position with knee flex seth relax the popliteal fossa (est mela ee, poplite! artery is palpated agaist ae ihe femur. | Posterior tibial artery: Palpated 2 em Bel behind the medial malleolus midway betwee tendon Achilles, against the calcanewm: a artery: Palpated anterioniy tnidwray between the two maleol agains tnd of tibia just above the ankle joint la ‘Extensor Hallucis Longus tendon. Dorsalis pedis; Palpated just lateral to thes allucis Longus tendon athe prox the groove between the 15" and’ against the navicular and middle the difference bed ‘hen counted si Normal: 60-100 / min. | Physfotogical: Infants | 2. Children:ned ove een with knee exed gp ibial tuberosity & p {ngers of each hand, yi palpated agama poate pleat blocks —Fimus bradycardia (60/ min) so Be vere hypoxia ’ Fypotnermia . fk sins syndrome iypotnyroidiso © Hopructive jaundice Poised intra cranial pressure 7 Wasovagal attack Drugs: Beta-blockers, Verapamil, Diltiazem, Digoxin ieficit (Apex-Pulse Defic Ttis the difference between the heart rate & pulse fate, when counted simultaneously for-one full ‘Sinus Trachycardia (°100/ min) my ee Pathological: ‘Tachyarrhythmia © High output states: = Thyrotoxicosis = Anaemia ~ Pyrexia ~ = Pheochromocytoma(@TAPP) = Beriberi ~ Cardic failure — CCardiogenic shock“ Hypovolemia Hypotension Drugs: Atropine, Nifedipine, Thyroxine, Catecholamines, Salbutamol Arrhythmias: = Atrial Fibrillation — = Atrial Flutter PSVT < ‘Ventricular tachycardia ~ Causes: fe Atrial fibrillation ‘= Ventricular premature beats ~~ <10/min Present Decreases or disappears ‘Ventricular premature beats hort pause followed by along pause-| ‘Atrial fibrillation >On, Absent ba Persists or increases “~ Pauses ae variable chaotic ed by palpating the radial artery: iy iregular shythm: ‘Arterial tachyamhytmias (PAT & arterial ution) th fixed AV block Ay iregular rhythm: Asal or ventricular ectopics\— Pulse volume: “Assessed by palpating the carotid artery. Pulse pressure gives accurate measure of pulse volume fe Normal volume pulse: 30-60 mmHg pulse pressure ‘e- Small volume pulse: Less than 30-60 mmig, pulse pressure fa Large volume pulse: Greater than 60 mmHgSe features {if any) I pro a because of objection of bolus of ‘plood Meera ota daring 31 Triste oly ptpable wae sls and generates atic after distention itrevols and porate E re which is T wave. some pressur ta during diastole. Because of esting pressure in aorta GUNNS jeri ote Hypokinetc pulse Sina weak pase (6mall volume and narrow pulse | | Fig: Hypokinerc puis i: Hyponete ise fictive pericardial disease Pals parvus Slow volume pulse d/t diminish lt verter vue congas hart flue or.a¥ in systemic arterial pressure Pu stole Slow ring pss at eas nein | Eg. Aortic stenosis se pulse ane wide pulse p tan tee eh 2d 2 fgh output states “Thyrotoxicosis “Anaemia AV fistula pyrexia = Pregnancy MR vsb ‘ ; pulse (Collapsing pulsefOaH ~» volume pulse with rapid upstroke var gh) sustained pe a Pres toke (dastolic pressures IOW)e Rapid upstroke: d/t markedly stroke volume; Rapid down stroke: d/t Diastolic leak back into left ventricle Rapid run off to the periphery systemic vascular resistance Procedure: a Palpate the wrist in such a way that fall on the radial artery and rest of over the ulnar artery. ‘= Examine the volume of the pulse both radial and ulnar artery) fora '= Now elevate the whole upper lil above the level of the heart & ny any changes in the volume of the} ‘= Abrupt downstroke of the pul collapsing feel. Right sided pulse shoul be hil standing on the right sides "sv Raise the arm to feel fOPt Jevate the arm: sto! cada to fall of Blood « Br scodilatation) and ths Yjostolic pressure more widens. oR 1¢ may be so that the art More in the Tine of aorta Bem, and thus allows dite Gisstolic backward flow of collapsing pulse: “nortic regurgitation Hyperkinetic circulatory ‘Anaemia Fever Thyrotoxcosis Pregnancy Exercise Beribert Patent cuuctusartriosu “Arteriovenous fistala fulsus Bisferiens: pulse wave with tw i/t Percussion wave (PSe al of Hod coll ase or | ions des yeelicgetonara) swardfow. | | Gj sortic regurgitation GF Hyperkinetic circulatory sates i upstroke (ysi peak and a ra Anaemia Fever Thyrotoxicosis Pregnancy Exercise = Beribert ip) Patent ductus arteriosus (PDA) IF Arteriovenous fistula BF Ruptured sinus of valsalva Palsus Bis le pulse wave with two peaks in systole Beat percussion wave (P) and 24 dt tidal wave Haaren: jection of pit of loo Hough Beta | fat in big arteries like brachial and femoral | vere aortic regurgitation Hypertrophic obstructive cardiomyopathy Fig: Pulsus Bisferiens ollapsiti ingle putse wave with one peak in systole and one peak in diastole. ‘Mechanism: D/t a very low stroke volume with decreased peripheral resistance. Left ventricular failure Typhoid fever Extreme dehydration Dilated cardiomyopathy Cardiac tamponade nalsus alternans: ‘Alternating small and large volume pulse in regular rhythm. Best appreciated by palpating radial, femoral pulses rather than carotid. Cause; Left ventricular failure Mechanism: ‘D/tatternating left ventricular contractile force ie altemate strong and weak beats. ‘Note; One should search for $3 gallop rhythmand ‘basal crepitation when pulse alternans is felt Fig: Pulsus alternons Pulsus bigeminus: ‘Normal beat followed by a premature beat and a ompensatory pause, occurring in rapid succession, sarang in alteration of the strength of the pulse, producing irregular rhythm.supe Digs toxic y Palos par esph Sig of ign atory pase! saree the BP cult 0 SUPFasystolic feel gl es sent whee asin puts RSA anil = compensatory pause SP Peaksystoic presume during oP OR a Po : Then cuffs dfted even mot slowly angi °°! rescporated inspiratory fallin systolic Pressure sien noted when KorotKoff sound berg Amy during quit thi 1 a sughout the respiration cya i sare Heart aounds are sll avaible at atime ere chen radial pus il ein ee Inflate the BP cuff to suprasytoliclevel and da © Consttive pericarditis i DE il Present if there is an alteration in the intensiyf Superior venacava obs conte " Inspiation ssessng the condtion of vessel Normaly arterial wal impalpable and may be papal inold aged/ arteriosclerosis ;, Inartriosclersis, the artery becomes tortuous tickeMufemo tues Ie cord k/a"Monckenberg’smedialsdem Gi. Ps doxus | Demonstration: hand ar Compress the brachial artery above tiga Mechanism: by ball of the left thumb and now roll the rad) ©auses: Noxmally, fallin systolic BP i < 1mm during artery over radius by index and middle ings | m_Coa Inspiration. Because of the right hand, Duringinpzaton therein intrathoracic pressure oR > poolingof ocd inpulmonary vasculature and | & First place the index and middle fingers of Fight ventricle > in venous return in left atrium & left and tight hand over radial artery side by: ‘ventricle in cardiac output, and exsanguinate the artery by moving the mi In puss paradoxus, more blood comes in right fingers in opposite direction, ventricle Which pushes the interventricular septum | © The radial artery is now rolled over the to theleft side 4 inthe volume of left ventricular by two index fingers. cavity Further in cardiac output. In cardiac tamponade: above effect + raised intrapericardal pressure (compresses the heart from, Raa Radioradial delay: Inacute severe asthma: and Radiof Simultaneously palpate both the arteries by bol Both ings ate expanded compres th heart Your and using your left and or ighada JSPs timely memes a ‘and vice versa for the other hand, | = Pulsus paradoxus —* Pulsus alterans Normal anatomical variation: "Thoracic inlet syndrome e.g. cervical rib Aneurysm of the arch of aortaslowly and ound best on eycle. ) pressures gupravalvular aortic stenosis, Feripheral embolism or atheromatous plaque iauneroxclerosis of aorta | pressure over axillary artery by ymphnode | iatrogenic: Blalock Taussing shunt operation in | Tetralogy of Fallot Readiofemoral del Gimultancously palpate the radial artery with left Fand and femoral artery of same side with right hand Tollook or the radio-femoral delay. Gis: B)Coarctation of aorta Atherosclerosis of aorta Thrombosis or embolism of aorta Acrtoartertis [ Carotid Brachial ee | Radiat __Rate Rhythm Tea ccathing pattern may be al bres — respiration Events Moving thea into and out of he 4 Met ethed entation ona. achanging ges between the int Cingn ad the blood ansport of oxygen to the body ee ae pnd the return of carbon dione, ee omy ; : _achanging gases between the blooad | @ Re Be Cohn) a : s Rate (RR Normal: Nervousness * Pain i o Fever © Hypoxia i Respiratory conditions: | = aie pulsonary oor Perce ines enntin nos Metblacidss = Asthma Rhyth It includes entire breathing (inspiration and expiration) cycle Duration of inspiratory phase is longer than expiratory phase with no pause in betw and this cycle occu ae = Women: Thoraco-abominal = Men: Abdomino- thoracic | | CGitSen > erect cbr lose ‘sig the oxygen in cel processes ae a Cardiae(left ventric Renal failure = Narcotic poisoning, fs Raised intracranial Ee ii. Kussmaul's breathing Al depth of breathing, pea idi = Metabolic acidosis- EI = Pontine lesions Narevi drug poisoning = Pontinel Raised intracranial tension. Cardiac arrest Reason: In males, diaphragms are stronger compared epnteon whe the oposite true for Depth: fers to the amount of ar thats inhaled andes Hyperventilation: Increase in depth of ntlation: Decrease in depth of rpnoea: Increase in rate and deplll respiraton ~ Acidosis ~ Brainstem lesion ~ Hysterian events no :ne nt and out of the nga. Re verttation! rgng ones between thesia th ratte bod portfongento the bea el Percent atoon doe rng gues between the Eso rey co ne onrgen in calprocesses at Sacto ot crbon deat Onna a mae | eet | followed by apnoea, 's Cardiac(left ventricular) failure fs Renal failure ‘s Narcotic poisoning, fs Raised intracranial pressure fi, Kussmaul's breathing: Increase in rate and depth of breathing, 2 Metabolic acidosis-DKA. = Pontine lesions b. Irregular abnormal pat = Uraemia = Hepatic failure Shock i. Biot's breathing: Apnoea between several shallow or few deep inspirations = Meningitis ‘Deep and shallow breaths ‘occurs randomly 18 Brain tem lesions fi, Apneustic breathing: Pause at full inspiration iterating witha pause in expiration, lasting, for 2t0 3 secs f= Pontine lesions iv. Cogwheel breathing: Interrupted type of breathing Nervous individuals +. Pursed lip breathing: Patients breathes out against pursed lip = COPD esp. Emphysema “Helps in increasing the intrabronchial pressure above the surrounding alveoli and prevents itscollapse