bp, hr, rr, temp, bmi e.g. patient is sitting/lying on the
TRANSCRIPT
BP,HR,RR,Temp,BMI
E.g.patientissitting/lyingonthebedinpain/comfortablywithnopainordistress.
Apathetic,anxious,mask-face,etc.
Facemask,tattoos,medicalbracelets,etc.
E.gneglected.
Vitiligo,obviousdiscoloration,etc.
Sweet,fetorhepaticus,etc.
Koilonychia,leukonychia,onycholysis,tarstains,p.cyanosis,andclubbing
Erythemaanddeformities(ulnardeviation,musclewasting,etc.)
CheckforbruisesandIVdrugsusage
Checkandcomparebothhandsusingthedorsalsurfaceofyourhand
Tendernessaccompaniedwithclubbingindicateshypertrophicosteoarthropathy
Hairoftheouter2/3
Eyeredness,pallorandjaundice
Angularstomatitis,glossitis,centralcyanosisanddentalhygiene
Visibleveins,scars,masses,skinchanges
Preauricular
Submental
Submandibular
Tonsilar
Ant.Cervical
Supraclavicular
Scalene
Post.uricular
Occipital
Post.Cervical
Ant.,Post.,Lateral,MedialandApical
Behindthemedialepicondyle,1-4cm
Byapplyingfirmpressure
Thoracictillumbilicus,45degrees,pillowunderhead
HR,RR,Temp,BP,BMI
Sitting/laying..Comfortably/indistress
Presenceofinhalers,O2therapy,etc.
Audiblesounds
Tarstaining,clubbing,P.cyanosis,discoloration(yellownailsyndrome)
Thenarmusclewasting,erythema
FineandFlapping
Comparepalmwithforearm
Tenderness(Hypertrophicosteoarthropathy)
Swellings,plethora,(pallor,jaundice,ptosis),(C.cyanosis,dentalhygiene,smell(smoker))
AssessJVP,cervicalLNs,accessorymuscleuse
Chestdeformities,patternofbreathing,symmetry,shape
Scars,swellings,visibleveins,skinchanges//Intercostalmuscleretractions//Hairdistribution//Axilla
Tug
Cricosternaldistance
Deviation
Palpablemassesordeformities
Tenderness
SubQemphysema
Apex,clavicle,2nd-6thribinAnt.//6thand8thribinlateral
5-8cm,ifless=pneumoniaorpneumothorax
Bronchial/vesicular
Wheezecanbepolyphonic(asthma),andmonophonic(mass)
Cracklescanbefine(pulmonaryfibrosis)orcoarse(bronchiectasis)
LethimsayE,ifheardasAthisindicatesconsolidation
Examinepittingedemaoversacrumandlumbar(RHF)
Ascitesandhepatomegalyseenincorpulmonale,RVhypertrophyandRVHF
LowerlimbsforsignsofDVTanderythemanodosum(sarcoidosis)
At45degrees,exposedfromthewaistandup
HR.RR,temp,BMI,O2sat
HTNcanbe:essential,secondary(<1%),orwhite-coatsyndrome
Patient'spositionandobviouscyanosis
Tobaccostain,p.cyanosis,clubbing,splinterhemorrhage
Tendonxanthoma,petechialrash
Palmarerythema,creasepallor,OslernodesandJanewaylesions
IVdruguseandtremor
Temp.,wet/dry
Xanthelasmata(periorbital)
Petechialhemorrhage,pallor,jaundice
Cornealarcus
HTNorDMchangesandRothspots
Malarflush(mitralstenosis)
C.cyanosis,dentalhygiene
-Diffuseinwardmovement-Twowavesperpulse
-Impalpable-Compressattherootoftheneckitwilldisappearwithpressure
-Varieswithrespiration(-withinspiration)-Lyingflat(+)-Abdominojugularreflux(+)
Betweentipofvisiblepulsationandthesternalangle//Unit:cmH2O
Venoushum
45degreeswiththeshouldershorizontal,exposetillthewaist
Chestshape,symmetry,breathingpattern,deformities
Hairdistribution,skinlesions,scars,visibleveins,skinchanges,apexbeatwithatorch
Askthepttorolltotheleftifitcan'tbefelt
Usingtheheelofthehandwhilethepatientholdshisbreathonexpiration
Usingthepadsofthefingers
Aorticarea:R-2ndICS
Pulmonaryarea:L-2ndICS
Mitralarea:apex(5thICS,mid-clavicularline)
Tricuspidarea:L-4thICSclosetotheleftsternalborder
Erb'spoint:L-3rdICSclosetotheleftsternalborder
ClosureofMV&TV,bestheardattheapex
ClosureofAV&PV,bestheardatlowerleftsternalangle
Earlydiastolic:'To-Ron-To',bestheardwiththebellattheapex.
Latediastolic/presystolic:'Ken-Tuck-Ky',bestheardwiththebellattheapex
Suddenopeningofastenosedvalveinearlydiastole(mostlyMS).Itisbestheardwiththediaphragmattheapex.
Suddenopeningofastenosedvalveinearlysystole(congenitalaorticorpulmonarystenosis).BestheardwiththediaphragmattheupperR/Lsternalborders.
Mostlyfrommitralvalveprolapseinlatesystolic.Bestheardwiththediaphragmattheapex.
Pericardialrub(frictionrub)isacoarsescratchingnoisebestheardwiththediaphragmwhileholdingbreathonexpiration.
Pleuropericardialrub
Gasinthepericardium(pneumopericardium)
Metallicsoundatsystole'S1'andaloudopeningsnapatdiastole'S2'.
Metallicsoundatdiastole'S2'andaloudopeningsnapatsystole'S1'.
HeartSoundsAuscultation
Auscultatethe4areas
AuscultatethecarotidbilaterallywhilethepatientholdshisbreathforASejectionsystolicmurmurradiationandcarotidbruits
AuscultatetheleftaxillaforMRradiation
AuscultatethetricuspidareaforTS
AuscultatetheapexforS3,S4andMS
Keepingthebellontheapex,askthepatienttoturntotheleftformid-diastolicMSmurmur
Usingthediaphragm,askthepatienttoholdhisbreathonexpirationandleanforwardwhileauscultatingtheaorticareaandErb'sareaforAR
HeartMurmurs
Determinewhetheritssystolicordiastolic
AR,PR
MS,AR(AustinFlint)
MSinapatientwithsinusrhythm,atrialcontractioncauseapresystolicaccentuationofthemurmur
Patentductusarteriosus
Harsh,blowing,musical,rumbling,high/lowpitched
MRpansystolicmurmurs->leftaxilla
ASmurmur->rtuppersternaledge,suprasternalnotchorcarotidarteries
VSDmurmurs->rightsternaledge
Exposebelowthewaistcoveringthegenitals.Askthepatienttofirstlieflat,dependentposition,thensupineelevated45degrees
BP.temp,BMI,O2sat,pulses(radial,brachial,carotid)
Tarstains,p.cyanosis,discoloration(Raynaud's)
Nailspittingandcalcinosis
Musclewastinginbothpalmaranddorsalaspects,tendonxanthoma
Amputations
Cornealarcusandxanthelasma
Ptosisandpapillarychanges(HornerSyndrome)
Hoarseness,visiblepulsation
Dilatedveins(axillay,subclavian)andJVP
Visiblepulsation(epigastricregion),skinmottling,stretchmarks(signsofwtloss)
Palpatetheepigastricregion(aorticaneurysm)andbelowtheumbilicus(iliacaneurysm)
Overabdominalaorta
Onycholysis,fungalinfectionb/wthetoes
Discoloration,dilatedveins,scars,masses,venousguttering
Hairloss(pattern),shinyskin,brittlenails
Ulcers(site,size,margin,depth,baseandsurroundingskin)
Ischemicchangesoftheheel(pressuresores)
Tendernessandtemperature(ankle,calf,thigh)bilaterally
Pulses(femoral,popliteal,post.tibialanddorsalispedis)
Capillaryrefill
1-Ptlyingsupine,fromthefootofthebed.2-Raisept’sfeet&supportlegsat45°for2–3minutes.3-Watchforpallorwithemptyingor‘guttering’ofsuperficialveins.4-Askpttositup&hanghislegsoverbed’sedge.5-Watchforreactivehyperemiaondependency.=>Lossofpallor&spreadingrednessarepositivesigns.
Flatwith1-2pillowsunderthehead-extendedarmsandlegs,exposedfromthexiphisternumtothesymphysispubis
BP,Temp,Pulse,RR,BMIandAutoSat
Commentontheweightandpain/distress
Clubbing,koilonychia,leuconychia,tarstaining
Palmarerythema,Dupuytren'scontracture,Musclewasting
Fineandflapping
Jaundice&Pallor
Xanthelasma
Ulcers,C.cyanosis,dentalhygiene,fetorhepaticus
Beefytongue,angularcheilitis,atrophicglossitis,
Cervical,axillaryandinguinal
Breast(atrophy/gynaecomastia),hairdistribution,scratchmarks,andspidernaevi
Abdomenshape,symmetry,umbilicus,andpatternofbreathing
Stria,stomas,scars,swellingsandscratchmarks.
Visibleveins,pulsationorperistalsis
Forhernias
Fordivaricationofrecti
Masses,tenderness,andguarding
Masses,tenderness,andguarding
ApplypressuretotheRIFusingthefingersthenquicklyremovethemandaskforpain
Askthepatienttobreatheoutandthenplaceyourhandbelowtherightcostalmarginatthemid-clavicularlinetopalpatethetipoftheGB
PlaceyourhandintheRIF,askthepatienttotakeabreathasyoumoveupwards1cmeachbreathuntilthemarginoftheliverisfelt
Percussfromthe2ICS(resonant)anddownwardsuntilreachingtheliver(dull)whilethepatientsholdshisbreathonexpiration.Theliverspanisb/wthispointandthepalpatedliveredge'spointinthepaststep.
PlaceyourhandintheRIF,askthepatienttotakeabreathasyoumovediagonally1cmeachbreathuntiltheMid-axillaryline.Thenaskthepatienttorolltoyoursideandredothemaneuver.
PercussstartingfromthemidaxillarylineRIFandmovediagonallydownthemarginuntilthenotechangesfromtympanictodull
Bimanual:Palpatebelowthecostalmargintofeelthekidneyswhiletheotherhandisattherenalangle.
Ballutmentpalpationisdonebyplacingonehandintherenalangle,behindthepatient,andpush,whiletheotherfeelsthekidneybelowthecostalmargin.
Hitattherenalangles
Startfromabovetheumbilicusandgodownalittle
Percussfromtheepigastricregionandmovedownwardsuntilhearingthehighesttympanicnote.Thenmovetotherightuntilyouheardullness.Askthepatienttorolltotheotherside,ifthenoteremainsdullthenthere'snoshifting.
Placethepalmofyourlefthandflatagainsttheleftsideofthepatient’sabdomenandaskthepatienttoplacetheedgeoftheirhandinthemidline(preventingtransmissionthroughtheskin)thenflickafingerofyourrighthandagainsttherightsideoftheabdomen.
UsingthediaphragmattheRIFforbowelsoundsfor4s
2cmabovetheumbilicusforaorticbruits,thenmove1cmlaterally(rightandleft)forrenalarterybruits.
Overtheliverandspleenforfrictionrubs
Cranial Nerves
▪ Optic Nerve
1- Inspect
▪ Periorbital edema
▪ Eyelids: proptosis, ptosis, lid lag and retractions.
▪ Conjunctiva: chemosis
▪ Sclera: redness
▪ Pupil: shape and symmetry at rest, pupillary reflex, RAPD, accommodation, anisocoria.
▪ Cornea: ulceration using fluorescein strips.
2- Palpate eyes’ orbits for masses
3- Homonymous defect
4- Sensory inattention
--------------------------------------------Cover one eye for the next steps----------------------------------------------
5- P. visual field (wiggling finger, white hatpin, red hatpin)
6- Color desaturation using a red hatpin
7- C. visual field using a red hatpin
8- Blind spot
-------------------------------------------------------Just mention----------------------------------------------------------
9- Test acuity using Snellen
10- Test color vision using Ishihara plates
11- Test macular function using Amsler grid
12- Fundoscopy for retinopathies
▪ CN 3,4,6
1- Draw an H for nystagmus
2- Pupillary reflex
▪ Vestibulocochlear
Whispered voice test
Weber’s test
Rinne’s test
▪ Trigeminal Nerve
Sensory: Touch, pain, common sensation from ant. 2/3, nasal tickle
Motor: mastication muscles weakness (temporalis, masseter), palpate masseter, open mouth against resistance
Reflexes: corneal, jaw jerk
▪ Facial Nerve
Sensory: taste from ant. 2/3
Motor: asymmetry (nasolabial folds, eyelids, forehead wrinkles), involuntary movements, raise eyebrow, show teeth,
shave (platysma), 2 resistance (eye ‘oculi’, cheeks ‘buccinator’)
Reflexes: corneal
▪ Glossopharyngeal Nerve
Sensory: common sensation and taste from pot. 1/3
Motor: palate ‘Ah’ (uvula deviation), air escape from the nose, bovine cough, swallow test
▪ Accessory Nerve
Trap and SCM, (inspect asymmetry or wasting), (palpate), (against resistance)
▪ Hypoglossal Nerve
Inspect tongue (wasting, fasciculations, involuntary movements)
Put tongue out (deviation, involuntary movements) // Side to side // Tongue against resistance
Say LaLaLa // Swallow test
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Motor
▪ Inspect: asymmetry, deformity, abnormal movements (tremors, myoclonic jerks, fasciculations)
▪ Palpate: bulk (hypertrophy, wasting), tenderness, symmetry
▪ Tone: UL, LL (roll, then briskly lift the leg), ankle clonus
▪ Power: UL, LL, pronator drift
▪ Reflexes: deep tendon, superficial (abdominal, cremasteric, plantar), Hoffman’s, finger jerk and primitive reflexes.
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Coordination
▪ Stance and gait: normal, tandem, Romberg’s
▪ Eyes: Nystagmus
▪ Speech: dysarthria, staccato
▪ Upper Limbs: tone, reflexes // Finger-to-nose (dysmetria, intention tremor or dyssynergia), rapid alt movement (dysdiadokinesia),
rebound phenomenon
▪ Lower Limbs: tone, reflexes // Heel-to-shin
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Sensory
▪ Touch, Pain, Temp
▪ Vibration, joint position
▪ Stereognosia, graphaesthesia
▪ Point localization, sensory inattention
Comment: normal power/tone
Sitting,exposedabovetheclavicle
HR,BP,Pulses,-Sinus-Rhythm,BMI,Temp,RR
Weight(loss,gain,normal)//Agitation,restlessness,apathy//Speech(hoarseness,slow,pressured)//Tachypnea
Vitiligo
Thyroidacropachy,brittlenails,onycholysis,clubbing
Palmarerythema,carpaltunnelsyndrome,musclewasting
Wet/sweatyorcold/dryhands,Finetremor
Sweaty/drycoarseskin/hair,hairlossfromtheouter2/3oftheeyebrows,preorbitalpuffiness
Redness,chemosis,ulcers,conjunctivitis,lidretractions
Opthalmoplagia(drawanH),lidlag,proptosis
Macroglossia(tonguethickening)
Inspect,askthepatienttoextendhisneck,swallowandprotrudethetongue.
Comment:•Symmetrical,withnomasses(thyroglossalcyst)orscars.•Movesupwardwithswallowing.
Lookatthebackofthetongueforlingualgoiter
Pembertonsign
Palpatetheneckwhileslightlyflexed,askthepatienttoswallowandprotrudethetongue.
Comment:•Symmetrical,normalshapeandsize,regularmargin.•Smoothwithnothrillsorhotness.•Nomasses(thyroglossalcyst)ortenderness-whetherdiffuseorlocalized.•Movesupwardwithswallowing.
Trachealdeviation
CervicalLNs
Manubriumdirectly
Auscultatetheglandforbruitusingthebell
Hipandbelow(ormid-thighandbelow)
Posture,Symmetry,Deformities(varus/valgus)
Patellarposition,Musclebulk
Redness,Rashes,Bruises
Scars,Swellings,Sinuses
Gait:askthepatienttowalk
Musclebulk
Ensuremusclebulksymmetrybymeasuringthecircumference20cmabovethetibialtuberosity
Feelthepatella,patellartendon,tibialtuberosity>Femoralandtibialcondyles>Jointline>Fibularhead
Feelthequadsmusclebulk
Temp.over,aboveandbelowthekneejointbilaterally
Tendonofquadricepsforsponginessoftenosynovitis
Activekneeextensionandflexionandlegelevation
Passivekneeextensionandflexionandlegelevationfromtheheels
Applyvalgusstress(pushthelegout,kneein).Redoitafterflexingtheleg30degrees
Applyvarusstress(pushthelegin,kneeout).Redoitafterflexingtheleg30degrees
First,flexthekneeandinspectfromthelateralsideforthePosteriorsagsign
Flextheknee,sitonthefoot,placeyourthumbsonthetibialtuberosityandthenpushtheleganteriorly(ACL)thenposteriorly(PCL)
LachmanTest:placeyourkneeunderthepatientskneeandthenanteriorlyandposteriorlywithdrawtheleg
Handholdingtheheel,otheronthejointline>elevatetheleg>legflexion>legexternalrotation>abductthehip>varusstress>extend
Handholdingtheheel,otheronthejointline>elevatetheleg>legflexion>leginternalrotation>adductthehip>valgusstress>extend
Lateralforceisappliedtothepatellawiththethumb.Thenmovesthekneefromfullextensionto90degofflexionandthenreturningtofullextensionwhilemaintainingthelaterallyappliedforceonthepatella.
Commentonabsenceofobliterationofparapatellargrooves(gutter)