History Takeing and Physical Examn..pdf

INTRODUCTION TO CLINICAL MEDICINE
By Dr Nathan B. (MD)

INTRODUCTION
 In the care of the suffering, the physicians need not only the scientific
knowledge of Medicine but also the technical skill and the
human understanding.
art science.
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 The practice of medicine therefore combines both art and science.
 Knowledge of the scientific basis of medicine refers to the vast
information on structure (anatomy), function (physiology) of the body,
processes of disease (pathology, microbiology), therapeutics
(pharmacology), etc.
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 The medical art is depicted in the skill of :
 interviewing the patient to elicit important information,
 the ability of using the senses to identify signs (disorders observed by a
physician) of abnormality on the body, and
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physician) of abnormality on the body, and
 judgment to extract the relevant symptoms (disorders notice by the patient
himself), signs, laboratory data.
 Clinical reasoning based on facts (symptoms and signs) in the history
and examination has to be tested against basic science background knowledge
acquired earlier.
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Ethical issues
 Respect- A physician should respect the patient by being nonjudgmental of
the lifestyle, attitude and values different from that of him/her self.
 Patient care-Caring for patients is an indispensable trait of a physician
who should have an interest in all, be it poor or rich, be it humble or proud.
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who should have an interest in all, be it poor or rich, be it humble or proud.
 Trust and confidence- In the absence of trust and confidence on the
part of the patient, the effectiveness of most therapies fails.
 A physician should have integrity by making himself available for help,
expression of sincere concern, taking time to explain the aspects of illness to
the patient.
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ethical… Cont’d
 Confidentiality -Maintaining confidentiality of medical
information encourages patients to seek treatment and
discuss their problems freely.
Autonomy - Patient’s autonomy involves the liberty to refuse
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 Autonomy - Patient’s autonomy involves the liberty to refuse
recommended intervention and choosing among the available
alternatives.
 Informing the patient adequately to be able to make decision to
accept or refuse an intervention before acquiring his consent or
permission is a physician’s duty.
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CLINICAL HISTORY AND PHYSICAL
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CLINICAL HISTORY AND PHYSICAL
EXAMINATION TECHNIQUES
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 Taking Appropriate history and doing comprehensive
physical examination is a basic for clinical medicine.
 It may enable us to diagnose disease in about 85% of cases.
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 It may enable us to diagnose disease in about 85% of cases.
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Components of Clinical History
1. Socio-Demographic Data These are:
i. The date and the time
ii. Patient Identification which includes:
 The full name
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 The Age and Sex
 Address
 Marital status
 Ethnic origin
 Religion
 Occupation
 Level of education
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History cont’d
2. Source of referral
3. Source of the history
 It helps to assess the value and possible bias of the information.
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 It helps to assess the value and possible bias of the information.
 The source can be the patient, family, friends, policeman, a letter
of referral, or the past medical record.
4. Previous Admissions:
 This is a list of hospitalization in the order they occurred.
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History cont’d
 In each case, specify the date, name and location of the health
institution, the disease that led to admission and the outcome as
briefly as possible.
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 If the previous admission is related to the present illness, it should
be described in the appropriate place in the history of the present
illness.
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History cont’d
5. Chief complaints (C/C):
 These are the major symptoms for which the patient is seeking
care or advice.
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 They should be written using the patients own words.
 The duration of the complaint should be specified.
Eg headache of 3 days duration
 Usually one ,but can be two or three.
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History cont’d
6. History of present illness (HPI):
 This section is a clear chronological (presenting or arranging in
order) account of the problems for which the patient is seeking
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care.
 This is the main part of history.
 The problems should be described as follows:
A. Date of onset: It is usually useful to start the history of the present
illness with the phrase “he/she was relatively healthy….”
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History cont’d
 B. Mode of onset, course and duration:
 Ask whether the onset was:
 abrupt or gradual
 intermittent or persistent
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 intermittent or persistent
 short lived or constant, and is the symptom
steady or increasing in severity
 C. Character and Location:
• Eg. pain, it is important to ask whether the pain is:
• Stabbing, burning, cramping, aching, radiating, colicky, etc.
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History cont’d
D. Exacerbating and Remitting Factors:
 For example, a chest pain, which always comes on after a
certain amount of exertion or made worse by exertion is
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almost certainly due to ischemia of the heart (angina).
 There can also be relieving factors for pains. For example, rest
usually promptly relieves upper gastro intestinal pains, like
duodenal ulcers.
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History cont’d
E. Effect of treatment:
 Patients might have taken drugs prior to their presentation to the health
institution.
It is very important to ask about the effect of such drugs on the illness.
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 It is very important to ask about the effect of such drugs on the illness.
F. Negative- Positive statements:
 These inquiries are conducted as thoroughly as possible with a view to
constructing a differential diagnosis.
 A negative statement may be as important as a positive statement.
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History cont’d
 For example, in a patient presenting with cough, statements
like “he denies night sweats, chronic cough, he has not lost
weight, he doesn’t have loss of appetite” are as important as
“he suddenly developed fever, chills, rigors, chest pain
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“he suddenly developed fever, chills, rigors, chest pain
aggravated by deep breathing, and cough productive of
yellowish sputum two days ago.”
 The negative statement tries to rule out pulmonary
tuberculosis, while the positive statement implies the
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History cont’d
7. Past illness:
 This includes important illnesses from infancy onwards.
 History of chronic illnesses like hypertension, diabetes mellitus,
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epilepsy, tuberculoses veneral diseases, etc
8. Personal – Social history:
It is recorded as follows;
i. Early development: place of birth and where the patient lived
before, childhood development, health and activities.
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History cont’d
 ii. Education: School history, achievements, and failures,
 iii. Marital status: whether the patient is married or not, history of
extramarital sexual activity.
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 Iv. Habits: dietary history; history of substance abuse like alcohol,
tobacco, chat, etc.
 One has to try to quantify the daily alcohol and tobacco
consumption.
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History cont’d
9. Family history:
 The family history of the patient is very important because it
provides information about the health status of immediate
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relatives and hereditary illnesses
 It is recorded as follows:
 Siblings: list their ages and current health status (If dead,
mention the date and possible cause of death)
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History cont’d
• Father and Mother: list their ages and current health
status (If dead, the date and possible cause of death
should be mentioned)
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should be mentioned)
• Familial Diseases: diseases like asthma, diabetes
mellitus, hypertensive disorders, migraine, etc should be
asked.
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History cont’d
10. Functional Inquiry (Systemic Review)
 The functional inquiry should be recorded as follows:
 H.E.E.N.T. (Head, Eye, Ear, Nose, Mouth and Throat)
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 H.E.E.N.T. (Head, Eye, Ear, Nose, Mouth and Throat)
 Head: Headache or injuries.
 Eyes: double vision, blurring, photophobia, itching, pain, redness,
excessive tearing, etc.
 Ear: hearing problem, tinnitus, vertigo, earaches, discharge, etc
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History cont’d
 Nose: frequent colds, nasal stuffiness, nasal discharge or itching;
nasal bleeding, etc.
 Mouth and Throat: sore tongue, frequent sore throat, and
hoarseness of voice, dry mouth, oral thrush, dental carries, etc.
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hoarseness of voice, dry mouth, oral thrush, dental carries, etc.
 Neck: pain, stiffness, swollen glands,”lumps”, etc
 Lympho-glandular system: This includes enlarged glands, lumps
in the breasts, and discharge from the nipples, goiter with or
without heat or cold intolerance , descent of testis, lymph node
enlargement, etc
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History cont’d
 Respiratory system:
 This includes inquiry about history of
 Cough
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 Production of sputum (including the odor, color and amount)
 Hemoptysis
 Difficulty of breathing
 Wheezing
 Chest pain
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History cont’d
 Cardiovascular system:
 This includes inquiry about history of:
 Dyspnea (including degree of exercise tolerance)
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 Dyspnea (including degree of exercise tolerance)
 Palpitation
 Orthopnea (number of pillows required), paroxysmal
nocturnal dyspnea
 Cough (dry or productive)
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History cont’d
 Hemoptysis
 Chest pain (With character, location and radiation)
 Syncope
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 Hypertension
 Swelling of the feet
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History cont’d
 Gastro intestinal system:
 This includes inquiry about history of
 Difficulty of swallowing, heartburn, nausea, vomiting, abdominal
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 Difficulty of swallowing, heartburn, nausea, vomiting, abdominal
pain, constipation, diarrhea, food intolerance, excessive belching
or passing of gas, frequency of bowel movement including the
color of stool passed, rectal bleeding, tarry stool, hemorrhoids,
and jaundice.
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History cont’d
 Genito – Urinary system:
 Urinary tract: History of flank pain, polyuria, nocturia, pain on
micturation, passage of blood , change in color of urine, urgency,
frequency, hesitancy, dribbling, incontinence, or passage of stone during
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frequency, hesitancy, dribbling, incontinence, or passage of stone during
urination.
 Integumentary system (Skin, Hair and Nails):
 History of dry or moist skin, rashes, ulcers, urticaria, hair distribution
and pigmentary changes, changes in color and shape of the fingernails.
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History cont’d
 Musculo- skeletal system:
 History of bony deformities, joint pain and /or swelling, limping,
loss of function of limbs or joints, leg swelling.
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 Central nervous system:
 History of fainting, seizures, weakness, paralysis, numbness or loss
of sensation, tingling sensation, tremor or other involuntary
movements, insomnia, poor memory, headache, disturbance of
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INTRODUCTION
 It is important to note that the key to a thorough and accurate
physical examination is developing a systematic sequence of
examination.
Examination should take place with good lighting and in a
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 Examination should take place with good lighting and in a
quite environment.
 It is advisable to examine a supine patient from the patient’s
right side.
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 By words or gestures, be as clear as possible in your
instructions.
 If possible try to demonstrate the patient what to do
rather than giving verbal instructions alone.
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rather than giving verbal instructions alone.
 Keep the patient informed as you proceed with your
examination.
 While examining the patient, it is helpful to move
“from head to toe.”
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 Be thorough without wasting time, systematic without being
rigid, gentle yet not afraid to cause discomfort
 The basic steps of physical examination are:
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 Inspection
 Palpation
 percussion
 Auscultation
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The Comprehensive Physical Examination
1. General Survey/general appearance:
 Is the patient acutely sick, chronically sick looking or not sick
looking at all? Is the patient in cardio respiratory distress or not?
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 Observe the patient’s general state of health
 Watch the patient’s facial expressions and note manner, affect,
and reactions to persons and things in the environment.
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 Listen to the patient’s manner of speaking and note the
state of awareness or level of consciousness.
 Note posture, motor activity, and gait; dress,
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grooming, and personal hygiene; and any odors of the
body or breath.
 The survey continues throughout the history and
examination.
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2. Vital Signs
 Measure the blood pressure - specify arm and the position it was
taken
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Technique of BP measurement
 Ideally, ask the patient to avoid smoking or drinking
caffeinated beverages for 30 minutes before the blood
pressure is taken and to rest for at least 5 minutes.
width of the inflatable bladder of the cuff should be
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 width of the inflatable bladder of the cuff should be
about 40% of upper arm circumference
 length of inflatable bladder should be about 80% of
upper arm circumference (almost long enough to
encircle the arm)

 Check to make sure the examining room is quiet and
comfortably warm.
 Make sure the arm selected is free of tight clothing.
 Palpate the brachial artery to confirm that it has a
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 Palpate the brachial artery to confirm that it has a
viable pulse.
 Position the arm so that the brachial artery, at the
antecubital crease, is at heart level. If the brachial
artery is much below heart level blood pressure
appears falsely high.

 If the patient is seated, rest the arm on a table a little
above the patient’s waist; if standing, try to support the
patient’s arm at the midchest level. The patient’s own
effort to support the arm may raise the blood pressure.
The lower border of the cuff should be about 2.5 cm
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 The lower border of the cuff should be about 2.5 cm
above the antecubital crease.
 To determine how high to raise the cuff pressure, first
estimate the systolic pressure by palpation. As you feel
the radial artery with the fingers of one hand, rapidly
inflate the cuff until the radial pulse disappears.

 read this pressure on the manometer and add 30 mm
Hg to it.
 deflate the cuff promptly at a rate of about 2 to 3 mm
Hg per second.
Note the level at which you 1st hear the sounds of at
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 Note the level at which you 1st hear the sounds of at
least two consecutive beats. This is the systolic pressure.
 Continue to lower the pressure slowly until the sounds
become muffled and then disappear. To confirm the
disappearance of sounds, listen as the pressure falls
another 10 to 20 mm Hg.

 Then deflate the cuff rapidly to zero. The
disappearance point, which is usually only a few mm Hg
below the muffling point, enables the best estimate of
true diastolic pressure in adults.
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 In some people, the muffling point and the
disappearance point are farther apart. Occasionally, as
in aortic regurgitation, the sounds never disappear. If
there is more than 10 mm Hg difference, record both
figures (e.g., 150/80/60).

 Blood pressure should be taken in both arms at least
once. Normally, there may be a difference in pressure
of 5 mm Hg and sometimes up to 10 mm Hg.
Subsequent readings should be made on the arm with
the higher pressure.
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the higher pressure.
 Pressure difference of more than 10–15 mm Hg
suggests arterial compression or obstruction on
the side with the lower pressure.

 In patients taking antihypertensive medications or patients with a history
of fainting, postural dizziness, or possible depletion of blood volume,
take the blood pressure in three positions—supine, sitting, and standing.
 Another measurement after 1 to 5 minutes of standing may identify
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Another measurement after 1 to 5 minutes of standing may identify
orthostatic hypotension missed by earlier readings.
 A fall in systolic pressure of 20 mm Hg or more, especially when
accompanied by symptoms, indicates orthostatic (postural) hypotension.

Category of blood pressure
Systolic (mm Hg) Diastolic (mm Hg)
Hypertension
 Stage 3 (severe) ≥180 ≥110
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 Stage 2 (moderate) 160–179 100–109
 Stage 1 (mild) 140–159 90–99
 High Normal 130–139 85–89
(prehypertension)
 Normal <120 <80
 Shock < 90 <60

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 Count the pulse rate - rate, volume, character, radio femoral delay
 Normal adult PR = 60-100 beats/ minute but physically fit people
may have as low as 45.
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 Tachcardia > 100 beats/ minute
 Bradycardia if < 60 beats/min

o Respiratory rate-Count the patient's respirations for a full
half-minute, starting when their attention is directed
elsewhere. It is convenient to do this when the patient thinks
you are still counting the pulse.
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you are still counting the pulse.
 The normal rate in an adult is about 14-20 breaths/minute,
but wide variations occur in health.
o Temperature- In conscious adults the temperature is taken in
the mouth or the axilla.

 In young children the thermometer should be placed in the fold of
the groin and the thigh flexed on the abdomen; or it may be inserted
into the rectum.
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 The temperature of the mouth and rectum is generally at least half a
degree higher than that of the groin or axilla.
 When taking the temperature, remember the following points:
 before inserting the thermometer, make it an invariable rule to
wash it in antiseptic or in cold water

 The thermometer must be accurate
 It must be kept in position long enough to allow the mercury to reach body temperature.
It is advisable to exceed the period the instrument professes to require
 normal core body temp. range= 36.5–37.5°C
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 An a.m. temperature of >37.2°C (>98.9°F) or a p.m. temperature of >37.7°C (>99.9°F)
defines a fever.
 Hyperpyrexia refers to extreme elevation in temperature, above 41.1°C (106°F), while
hypothermia refers to an abnormally low temperature, below 35°C (95°F) rectally.
Thermometry? thermometer?

o Height and Weight measurement
 BMI=Wt(Kg)/(Ht(m))²
WHO classification of obesity
Category BMI
Underweight <18.5
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Underweight <18.5
Healthy weight 18.5-24.9
Overweight 25-29.9
Moderately obese 30-34.9
Severely obese 35-39.9
Morbidly obese >40

o Mid-upper arm circumference (MUAC)
 If neither height nor weight can be measured or obtained,
nutritional assessment can be estimated using the mid-upper
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arm circumference.
 Mid point between the top of shoulder (acromion)and the
point of the elbow (olecranon process) of non dominant hand
will be measured.

 If the MUAC is ≥25cm the BMI is likely to be ≥20.
 If the MUAC is ≥23.5cm and <25cm, the BMI is likely to be
≥18.5 and <20.
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 If the MUAC is <23.5cm then the BMI may be <18.5.
 If the MUAC measurement changes by at least 10% then it is
likely that weight and BMI have changed by approximately
10% or more.

HEENT
a. Head
 Hair- quantity, distribution, texture, and pattern of loss, if any.
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You may see loose flakes of dandruff
 Scalp-apart the hair in several places and look for scaliness,
lumps, nevi, or other lesions
 Skull-observe the general size and contour of the skull, any
deformities, depressions, lumps, or tenderness

 Face-note the patient’s facial expression and contours. Observe for
asymmetry, involuntary movements, edema, masses, its color,
pigmentation, and any lesions
b.Eyes
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b.Eyes
 Color of sclera and conjunctiva
*normal-pink conjunctiva and nonicteric sclera
*abnormal-pale conjunctiva(anemia),injected/red
conjunctiva(conjunctivitis) and icteric/yellowish sclera(jaundice)

c.Ears
 Auricle-Inspect each auricle and surrounding tissues for
deformities, lumps, or skin lesions
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 Movement of the auricle and tragus (the “tug test”) is painful in
acute otitis externa (inflammation of the ear canal), but not in
otitis media (inflammation of the middle ear).
 Tenderness behind the ear may be present in otitis media.

d.Nose and Para nasal Sinuses
 Note any asymmetry or deformity of the nose. Some asymmetry
of the two sides is normal.
Test for nasal obstruction, if indicated, by pressing on each ala
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 Test for nasal obstruction, if indicated, by pressing on each ala
nasi in turn and asking the patient to breathe in.
 Palpate for sinus tenderness- Press up on the frontal sinuses from
under the bony brows, avoiding pressure on the eyes. Then press
up on the maxillary sinuses.

 Local tenderness, together with symptoms such as pain, fever, and nasal
discharge, suggests acute sinusitis involving the frontal or maxillary
sinuses.
 Transillumination may be diagnostically useful.
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e. Mouth and Pharynx
 Lips-observe their color and moisture, and note any lumps, ulcers,
cracking, or scaliness
 Oral Mucosa- with a good light and the help of a tongue blade, inspect
the oral mucosa for color, ulcers, white patches, and nodules.

 If you detect any suspicious ulcers or nodules, put on a glove and
palpate any lesions, noting especially any thickening or infiltration
of the tissues that might suggest malignancy.
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 Inspect the sides and undersurface of the tongue and the floor of
the mouth. These are the areas where cancer most often develops.
 Note any white or reddened areas, nodules, or ulcerations

4. LYMPHO GLANDULAR SYSTEM
Introduction
 The lymph nodes are affected in many ways either directly or indirectly
from diseases that originate in the lymphatic system itself or from any
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from diseases that originate in the lymphatic system itself or from any
other organ system.
 The lymphatic circulation is an alternative circulation system in which
heavy molecular weight substances are carried back to the circulation
from tissues, and obviously, it also serves as a filtration in phagocytosis
and immunological activities.

 The lymph nodes in most of the region are accessible to physical
examination.
 The lymphatic drainage in a given tissue or organ system is
initially to certain group of lymph nodes.
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initially to certain group of lymph nodes.
 The accessible lymph node groups in our body for physical
examination are:
 Cervical lymph node groups
 Axillary lymph node groups

 Supraclavicular lymph node groups
 Inguinal lymph node groups
 Para aortic lymph node groups etc
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Cervical lymph node group: are affected usually by neck and
face pathologies.
 They are also involved in systemic illness such as lymphomas,
tuberculosis, and pyogenic infections.

 The lymph nodes may be:
 matted together e.g. Tuberculosis
 discreetly enlarged e.g. Lymphomas
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 hard or soft in consistency depending up on the pathology
 small or big size(significant>1x1cm)
 associated with discharge
 Painful(inflammatory) or painless

Groups of lymph node found in the neck region
1. Pre auricular
2. Posterior auricular
3. Occipital
4. Tonsilar
5. Sub mandibular
6. Sub mental
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6. Sub mental
7. Superficial cervical
8. posterior cervical
9. Deep cervical
10.Supraclavicular

 Each of this node groups are affected by different pathologies. It
is therefore mandatory to be able to examine the nodes affected,
as it is related to the understanding of the nature of the primary
problem.
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problem.
Axillary lymph nodes: are commonly affected
group by metastasis from breast carcinoma.
 The examinations of these lymph nodes are systematically
approached.

 Even though, it is part and parcel of the examination of
breasts, axillary lymph nodes are frequently involved in
pathologies of neoplastic or inflammatory origin.
 Examination of axillary lymph nodes is done
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 Examination of axillary lymph nodes is done
o The patient being best in sitting position
o Pectoralis muscles should be relaxed,
o Examiner sitting on the same side of the axilla then
palpate systematically the five groups of lymph nodes

 The examination of lymphatic system of the axilla with out
palpating the supraclavicular and infraclavicular lymph node
groups will not be complete.
Inguinal lymph nodes: are found along the inguinal canal
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Inguinal lymph nodes: are found along the inguinal canal
 They often are affected from infection around the lower extremity
and the external genitalia.
 Malignant diseases occurring in the scrotum and penis also affect
this lymph node groups

Para aortic lymph nodes: are not usually accessible to physical
examinations unless the patient is thin or wasted. Colorectal carcinoma
metastasizes to these lymph nodes
Pre trochlear nodes: are located close to the elbow joint and affected by
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Pre trochlear nodes: are located close to the elbow joint and affected by
syphilis.
Examination of the Breast
History
 Common breast complaints are:
 lump in the breast

 breast pain
 nipple discharge and
 ulceration
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 Different breast pathologies tend to occur in different age
groups. E.g. breast lump in a teenager is most likely to be a
fibro adenoma, where as in elderly women it’s likely to be
cancer.

 Breast lump: commonest breast complaint. ask about: duration,
any accompanying nipple discharge, parity and breastfeeding
experience, how it was first noticed, change in size relation to
menses, family history of same illness or ovarian tumor,
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menses, family history of same illness or ovarian tumor,
symptoms of TB,mobility etc.
 Breast pain: It is mostly of functional and inflammatory origin.
ask about: site(which quadrant), severity, associated swelling,
lump, discharge, relation to menses, pregnancy, lactation etc

 Nipple discharge: ask about
 color (bloody, serous, purulent, milky, etc)
 spontaneous Vs non-Spontaneous
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 unilateral Vs bilateral
 relation to menstrual cycle
 associated breast lump
 drug intake E.g. Oral contraceptives

Physical Examination
 Specific goals of examination are to:
o detect and characterize breast mass or masses
o elicit discharge from the nipple
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o elicit discharge from the nipple
o relate pain compliant to a specific breast finding
o detect skin changes
o detect enlarged axillary, supraclavicular or infraclavicular lymph
nodes
o detect metastasis (If breast cancer suspected)

a. Inspection
Stand in front of the patient and look at the:
 size of breast
 symmetry and contour of breast
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 symmetry and contour of breast
 nipple & areola for, symmetry, retraction, discharge
 skin for retraction, discoloration, “peau d’ orange” appearance
nodules and ulceration
 repeat the inspection with the patient raising her arms above the
head. Inapparent retractions and asymmetries may be evident now.

b.Palpation
 palpate with the palmar surface of your fingers
quadrant by quadrant
 check for
 skin temperature
 consistency of breast, nodularity
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 consistency of breast, nodularity
 tenderness
 nipple discharge (expression)
 mass(discrete or indiscrete, position in the breast,
number, shape & size)

 Examine for distant metastasis: look for
pallor, jaundice
bone tenderness or swelling
pleural effusion
hepatomegaly
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hepatomegaly
neurological deficits
Read on breast-self examination

5. The Respiratory System
 It is helpful to examine the posterior thorax and lungs while the patient is
sitting, and the anterior thorax and lungs with the patient supine.
 it is possible to examine both the back and the front of the chest with the
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patient sitting.
 Proceed in an orderly fashion:
 Inspect
 Palpate
 Percuss
 Auscultate.
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 Try to visualize the underlying lobes, and compare one side with
the other, so the patient serves as his or her own control.
 Arrange the patient’s gown so that you can see the chest fully.
 For women, drape the gown over each half of the anterior chest as
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 For women, drape the gown over each half of the anterior chest as
you examine the other half.
 Cover the woman’s anterior chest when you examine the back.
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Inspection
 Assess the patient for cyanosis (nail bed, lips and tongue)
and fingers for clubbing
 Listening to the patient’s breathing if there are additional
sounds like wheezes or strider.
 The respiratory rate and rhythm depth, and effort of
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 The respiratory rate and rhythm depth, and effort of
breathing.
A normal resting adult breathes quietly and regularly
about14 to 20 times a minute.
 Also observe the shape of the chest.
 Deformities or asymmetry
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 Signs of respiratory distress:
Flaring of ala-nasae
Intercostal retraction
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Intercostal retraction
Subcostal retraction
The use of accessory muscles in the neck
 Impaired respiratory movement on one or both sides
or a unilateral lag (or delay) in movement.
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PALPATION
 Palpation of the chest has four potential uses:
o Tracheal location:
Feel for the trachea in the suprasternal notch and
decide whether it is central or deviated to one
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decide whether it is central or deviated to one
side by inserting fingers between the suprasternal
notch and the insertion of the sternomastoids
muscles.
o Identification of tender areas and checking for
abnormalities such as masses or sinus tracts.
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 Test chest expansion
Place your thumbs at about the level of the 10th ribs,
with your fingers loosely grasping and parallel to the
lateral rib cage.
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lateral rib cage.
As you position your hands, slide them medially just
enough to raise a loose fold of skin on each side
between your thumb and the spine.
Ask the patient to inhale deeply.
Watch the distance between your thumbs as they move
apart during inspiration, and feel for the range and
symmetry of the rib cage as it expands and contracts.
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 Feel for tactile fremitus
Fremitus refers to the palpable vibrations transmitted
through the bronchopulmonary tree to the chest wall
when the patient speaks.
 To detect fremitus, use either the ball (the bony part of
the palm at the base of the fingers) or the ulnar surface
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the palm at the base of the fingers) or the ulnar surface
of your hand to optimize the vibratory sensitivity of the
bones in your hand.
 Ask the patient to repeat the words “ninety-nine” or
“one-one-one.” or the amharic word “Arba-Arat”
 If fremitus is faint, ask the patient to speak more loudly
or in a deeper voice.
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 Fremitus is decreased or absent:
When the voice is soft
When transmission of vibrations from the larynx to
the surface of the chest is impeded.
The cause can be an obstructed bronchus, pleural
effusion, pulmonary fibrosis, pneumothorax or very
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effusion, pulmonary fibrosis, pneumothorax or very
thick chest wall.
 Fremitus is increased
when the transmission of sound is increased, as
through the consolidated lung of lobar pneumonia.
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Palpate and compare
symmetric areas
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PERCUSSION
 one of the most important techniques of physical
examination.
 helps you establish whether the underlying tissues are
air-filled, fluid-filled, or solid.
 When percussing the lower posterior chest, stand
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 When percussing the lower posterior chest, stand
somewhat to the side rather than directly behind the
patient.
 When comparing two areas, use the same percussion
technique in both areas.
 Percuss or strike twice in each location.
 Normal lungs are resonant.
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 Dullness
 Resonance
 Hyperresonance
 Tympany
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 Tympany
 While the patient keeps both arms crossed in front of
the chest, percuss the thorax in symmetric locations
from the apices to the lung bases.
 Percuss one side of the chest and then the other at
each level
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4. AUSCULTATION
 Auscultation of the lungs is the most important
examining technique for assessing air flow through the
tracheobronchial tree.
 Auscultation involves:
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 Auscultation involves:
listening to the sounds generated by breathing
listening for any adventitious (added) sounds
listening to the sounds of the patient’s spoken or
whispered voice as they are transmitted through
the chest wall.
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Normal breath sounds are:
 Vesicular
soft and low pitched.
are heard through inspiration, continue without
pause through expiration, and then fade away
about one third of the way through expiration.
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about one third of the way through expiration.
heard over most of both lungs
 Bronchial
louder and higher in pitch
with a short silence between inspiratory and
expiratory sounds. Expiratory sounds last longer
than inspiratory sounds.
heard over the manubrium, if heard at all
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 Bronchovesicular
inspiratory and expiratory sounds about equal in
length
at times separated by a silent interval
heard often in the1st and 2nd Interspaces anteriorly
and between the scapulae
Techniques of auscultation
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Techniques of auscultation
 Instructing the patient to breathe deeply through an open
mouth.
 Listen to the breath sounds with the diaphragm of a
stethoscope
 Use the pattern suggested for percussion, moving from one
side to the other and comparing symmetric areas of the
lungs. 5/20/2023
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Adventitious (Added) Sounds
 sounds that are superimposed on the usual breath
sounds.
 Wheezes-musical sounds associated with air way
narrowing.
suggest narrowed airways, as in asthma,
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suggest narrowed airways, as in asthma,
COPD, or bronchitis.
 Crackles-are short, explosive sounds often described
as bubbling.
 Rhonchi-have a snoring quality.
suggest secretions in large airways.
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Transmitted Voice Sounds
 Bronchophony - Ask the patient to say “ninety-nine.”
Louder, clearer voice sounds are called bronchophony.
 Egophony - Ask the patient to say “ee.” When “ee” is
heard as “ay,” an E-to-A change (egophony) is present,
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heard as “ay,” an E-to-A change (egophony) is present,
as in lobar consolidation from pneumonia. The quality
sounds nasal.
 Whispered pectoriloquy - Ask the patient to whisper
“ninety-nine” or “one-two-three.” Louder, clearer
whispered sounds are called whispered pectoriloquy.
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Cardiovascular System
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Techniques of Examination
Arterial Pulses
Major Arteries:
 Radial, Brachial, Carotid, Femoral, Popliteal, Dorsalis pedis
and tibialis posterior .
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and tibialis posterior .
 All arteries should be palpated symmetrically at the same time
except carotid arteries.
 Characterise arterial pulse (rate, rhythm, volume radio-
femoral delay)
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Jugular Venous Pressure (JVP)
 JVP reflects pressure in the right atrium, or central venous
pressure
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 Is best assessed from pulsations in the right internal jugular vein.
 Difficult to see in children younger than 12 years of age
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Steps for assessing JVP
 Raise the head slightly on a pillow
 Raise the head of the bed or examining table to about 30°.
 Turn the patient’s head slightly away from the side you are
inspecting.
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inspecting.
 Use tangential lighting and find the internal jugular venous pulsations
 If necessary, raise or lower the head of the bed until you can see the
oscillation point
 Identify the highest point of pulsation in the right internal jugular
vein. 5/20/2023
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 Extend a long rectangular object or card horizontally from this point and a
centimeter ruler vertically from the sternal angle, making an exact right angle.
 Measure the vertical distance in centimeters above the sternal angle where the
horizontal object crosses the ruler.
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 This distance, measured in centimeters above the sternal angle or the atrium, is the
JVP.
 Venous pressure measured at greater than 3 cm or possibly 4 cm above the sternal
angle, or more than 8 cm or 9 cm in total distance above the right atrium, is
considered elevated above normal.
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Dr. Nathan B.

Distinguish JVP from carotid artery pulsations:
Internal Jugular Pulsations Carotid Pulsations
 Rarely palpable
 Soft, with two elevations and two
troughs per heart beat
 Palpable
 more vigorous thrust with a single
outward component
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troughs per heart beat
 eliminated by light pressure
 Level of the pulsations changes
with position
 Level of the pulsations usually
descends with inspiration.
outward component
 not eliminated by light pressure
 Level of the pulsations unchanged by
position
 Level of the pulsations not affected by
inspiration
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The Precordium
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Inspection:
 look for:
 Precordial bulge-may indicate long standing cardiac diseases
Precordial movement ( activity )
 Precordial movement ( activity )
 Multiple pulsations
 Quiet
 Apical impulse- which is the most laterally and downward
positioned impulse.
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Palpation
 Palpable heart sounds (at each valvular sites)
 PMI: point of maximal impulse (which usually is located at the
same area to the apical impulse,).
 It is normally located in the 4th or 5th intercostal space just
medial to the mid clavicular line
 Thrills (a palpable murmur)
 Heave (lifting the palm or a pen when put on the area)
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Characterization of the Impulse(PMI)
 Location: site as intercostal space and medial or lateral to the
midclavicular line,
 Size: diffuse if more than two intercostal spaces or not diffuse
if otherwise (greater than 2.5 cm in diameter)
 Duration: sustained if more that 2/3 of the systolic time or not
if otherwise
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Percussion:
 Has little significance in precordial examination.
 It is done when one suspects dextrocardia or significant
mediastinal shift.
mediastinal shift.
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Auscultation
 Areas of auscultation:
1.The right 2nd interspace near the sternum (aortic area).
2. The left 2nd interspace near the sternum (pulmonic area).
3. The left 3rd 4th, or 5th inter spaces near the sternum (tricuspid
area)
4. At the apex (mitral area).
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During auscultation focus on
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 1st Heart Sound, S1
 2nd Heart Sound, S2
 3rd & 4th Heart Sounds
 Murmur-abnormal sound due to turbulence of blood flow.
Characterization of Murmur
 Timing: systole, diastole, continuous
 Point of maximum intensity
 Direction of selective propagation (radiation)
 quality -blowing, harsh, rumbling, and musical.
 Intensity (grading)
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Grading of murmur
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 1/6 -Very faint, only heard with optimal conditions, no thrill
 2/6 -Loud enough to be obvious, no thrill
 3/6 -Louder than grade 2, no thrill
4/6 -Louder than grade 3, there is thrill
 4/6 -Louder than grade 3, there is thrill
 5/6 -Heard with the stethoscope partially off the chest, thrill
present
 6/6 -Heard with the stethoscope completely off the chest, thrill
present
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THE ABDOMEN
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 The abdomen is often divided by imaginary lines crossing at
the umbilicus, forming the right upper, right lower, left upper,
and left lower quadrants.
 Another system divides the abdomen into nine sections.
 Terms for three of them are commonly used: epigastric,
umbilical, and hypogastric or supra-pubic.
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Right
hypochondrium
Left
hypochondrium
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Right lumbar Left lumbar
Right iliac
Left iliac

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 Full exposure of the abdomen from above the xiphoid process to
the symphysis pubis.
 The groin should be visible.
 The genitalia ought to remain draped.
 The abdominal muscles should be relaxed to enhance all aspects
of the examination, but especially palpation.
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 The patient should have an empty bladder.
 Examine in a supine position, keep arms at the sides or folded
across the chest.
 Warm your hands and stethoscope
 Distract the patient if necessary with conversation or questions.
 proceed in an orderly fashion with inspection, auscultation,
percussion, and palpation; assess the liver, spleen & kidneys
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INSPECTION
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 The skin
 Scars
 Striae
 Dilated veins
 Rashes and lesions
 Rashes and lesions
 The umbilicus
 The contour of the abdomen
 Is it flat, protuberant, or scaphoid
 Do the flanks, inguinal and femoral areas bulge? (ascites, hernias)
 Is the abdomen symmetric?
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AUSCULTATION
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 Before performing percussion or palpation, since these maneuvers may alter the
frequency of bowel sounds.
 Bowel sounds and note their frequency and character.
 Normal sounds- clicks and gurgles
 Normal sounds- clicks and gurgles
 estimated frequency of 5 to 34 per minute.
 Occasionally you may hear borborygmi - long prolonged gurgles of
hyperperistalsis
 listening in one spot, such as the right lower quadrant, is usually sufficient.
 Bruits - listen in the epigastrium and in each upper quadrant (vascular sounds
resembling heart murmurs) 5/20/2023
Dr. Nathan B.

A bruit in one of these
areas that has both systolic
and diastolic components
renal
strongly suggests renal
artery stenosis as the
cause of hypertension.
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PERCUSSION
120
 Percuss the abdomen lightly in all four quadrants- tympany and
dullness
 Tympany usually predominates because of gas in the
gastrointestinal tract
 Test for shifting dullness (ascites)
 After mapping the borders of tympany and dullness,
ask the patient to turn onto one side. Percuss and mark
the borders again.
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121
 Test for a fluid wave (thrill)
 Ask the patient or an assistant to press the edges of
both hands firmly down the midline of the abdomen
 While you tap one flank sharply with your fingertips,
feel on the opposite flank for an impulse transmitted
through the fluid
 An easily palpable impulse suggests ascites
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PALPATION
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 Before you begin palpation, ask the patient to point to any areas of pain and
examine these areas last.
 Watch the patient’s face closely for any signs of pain or discomfort
 If the patient is frightened, begin palpation with the patient’s hand under yours
 If the patient is frightened, begin palpation with the patient’s hand under yours
Light Palpation
 Superficial abdominal tenderness, organs and masses
 It also serves to reassure and relax the patient
 Moving smoothly, feel in all quadrants
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124
Deep Palpation
 To delineate abdominal masses and to detect deep tenderness
 Again feel in all four quadrants
 Identify any masses and note their location, size, shape,
consistency, tenderness, pulsations, origin and any mobility with
respiration or with the examining hand
 Look for rebound tenderness - Press your fingers in firmly and
slowly, and then quickly withdraw them
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125
The Liver
 Measure the vertical span of liver dullness in the right midclavicular line.
 Starting at a level below the umbilicus (in an area of tympany), lightly percuss
upward toward the liver. Ascertain the lower border of liver dullness in the
midclavicular line
 Next, identify the upper border of liver dullness in the midclavicular line.
Lightly percuss from lung resonance down toward liver dullness.
 Now measure in centimeters the distance between your two points
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127
Palpation for the liver
 Place your left hand behind the patient, parallel to and
supporting the right 11th and 12th ribs and adjacent soft tissues
below.
 Place your right hand on the patient’s right abdomen, press
gently in and up
 Ask the patient to take a deep breath. Try to feel the liver edge as
it comes down to meet your fingertips.
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The Spleen
129
 Percuss the left lower anterior chest wall between lung resonance above
and the costal margin (an area termed Traube’s space)
 Percuss the lowest interspace in the left anterior axillary line
 The spleen has to be enlarged two to three times its normal size to be
palpable
palpable
 It grows downwards and towards the right iliac fossa
 With your right hand below the left costal margin, press in toward the
spleen, supporting with the left hand
 Measure the distance between the spleen’s lowest point and the left costal
margin.
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131
Factors that aid in differentiating an enlarged kidney from an enlarged spleen
include:
 The presence of a dullness anterior to an enlarged spleen and not anterior to an
enlarged kidney
 In reference to inspiration, the spleen moves downward; the kidney does not
move.
 Enlarged kidney is bimanually palpable, the spleen can’t be palpated bimanually.
 The presence of a notch on the medial aspect of an enlarged spleen
 Inability to pass or insert fingers in the sub costal margin in case of the spleen
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132
Assessing Kidney Tenderness
 Costovertebral angle tenderness- place the ball of one hand in the
costovertebral angle and strike it with the ulnar surface of your fist.
Special Techniques
Identifying an Organ or a Mass in an Ascitic Abdomen
 to ballotte the organ or mass straighten and stiffen the fingers of
one hand together, place them on the abdominal surface, and make
a brief jabbing movement directly toward the anticipated structure
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133
Assessing possible appendicitis
 Ask the patient to point to where the pain began and where it is now.
 Search carefully for an area of local tenderness.
Rovsing’s sign and referred rebound tenderness. Press deeply and evenly
 Rovsing’s sign and referred rebound tenderness. Press deeply and evenly
in the left lower quadrant. Then quickly withdraw your fingers
 psoas sign- place your hand just above the patient’s right knee and ask the
patient to raise that thigh against your hand
 obturator sign- flex the patient’s right thigh at the hip, with the knee bent,
and rotate the leg internally at the hip.
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THE NERVOUS SYSTEM
134
Components:-
 Mental status examination
 Cranial nerves 1 through 12
 Motor examination including deep tendon reflexes
 Superficial reflexes
 Primitive reflexes
 Motor Coordination
 Posture, station and gait.
 Sensory system: pain and temperature, position and vibration, light touch, discrimination
 Signs of meningeal irritation
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Glasgow Coma Scale
135
1. Eye opening (E) 3.Verbal response (V)
Spontaneous-------4 Oriented-----------------5
To loud voice-------3 Confused, disoriented--4
To pain-------------2 Inappropriate words---3
Nil------------------1 Incomprehensible sounds---2
2. Best motor response (M) Nil------------------------1
2. Best motor response (M) Nil------------------------1
Obeys command----------6
Localizes-------------------5
Withdraws----------------4
Abnormal flexion posturing---3
Extension posturing-------2
Nil--------------------------1
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Dr. Nathan B.

C. Speech and language
 Quantity, rate, loudness, articulation of words, fluency
D. Thought and perception
 Any unusual aspects of thought, illusions or delusions and insight.
E. Cognitive function
Orientation to time, place, and person.
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136
 Orientation to time, place, and person.
 Memory:
 Immediate- recall by saying a series of numbers and having the patient
repeat them
 Recent memory- to recall something after 5 minutes has elapsed
 Remote memory- refers to events in the distant past.

THE CRANIAL NERVES (CN)
Overview:
I Smell
II Visual acuity, visual fields, and ocular fundi
II, III Pupillary reactions
III, IV, VI Extraocular movements
V Corneal reflexes, facial sensation, and jaw
movements
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movements
VII Facial movements
VIII Hearing
IX, X Swallowing and rise of the palate, gag reflex
V, VII, X, XII Voice and speech
XI Shoulder and neck movements
XII Tongue symmetry and position

1. Cranial Nerve I- Olfactory
 Test the sense of smell by presenting the patient with familiar and non irritating
odors
2. Cranial Nerve II—Optic
2.1. Testing of the visual fields
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138
 Confrontation method:
 Stand and sit a meter away from patient who looks fixedly at your nose
with one eye, while covering the other eye.
 Move small object or a moving finger slowly from the periphery to the
center until noted by the patient
 This is compared with the examiners field of vision and done in all
quadrants

2.2 Visual acuity
 Snellen’s chart
 Use finger counting and reading
2.3 Funduscopy
 Can be used to visualize the optic disk which could be inflamed or
5/20/2023
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140
edematous due to increased intracranial pressure.
3. Third, fourth, and sixth cranial nerves(Oculomotor, Trochlear, and
Abducens)
 The third, fourth and sixth cranial nerves are checked together
 Test the movement of the eye balls in all directions

 Examine the pupils for:
Size & Symmetry
Pupilary light reflex
4. The fifth cranial (Trigeminal) nerve
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141
4. The fifth cranial (Trigeminal) nerve
 Motor examination of jaw movement
Ask the patient to move the jaw from side to side, and bite
strongly.
Palpate the masseter and temporalis muscles as the patient
clenches his teeth.

142
 Sensory examination of the three
divisions of the trigeminal nerve-the
examiner tests light-touch sensibility
with a cotton and pain by pricking
with a cotton and pain by pricking
with a pin the patient’s forehead, the
area of the mandible and the maxilla.
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143
 Corneal reflex
The patient is asked to look
upward while the examiner
uses the wisp of cotton
uses the wisp of cotton
carefully and to briefly
stroke the cornea from the
side and from below. The
normal response is blinking.
5/20/2023
Dr. Nathan B.

 5. The seventh (facial) nerve:
 Evaluation of the motor function
 Inspection for flattening of the nasolabial fold,
facial droop or asymmetry
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 Then ask the patient to
 Frown, raise eye brows
 Close his eye tightly against pressure,
 Smile or show upper teeth,
 Blow cheek
 Whistle.

 The sensory portion of the seventh nerve:- is tested by
applying crystals of salt and sugar from two
moistened cotton applicators on different aspects of the
tongue.
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tongue.
6. The eighth (vestibule-cochlear/Acoustic) nerve:
 Testing Cochlear portion is done by assessing the ability
to hear using:-
 Whispered and spoken voice,

146
7. The ninth cranial (glosso pharyngeal) nerve
 Checking for taste over the posterior third of the tongue.
 -A portion of the ninth nerve and a portion of the tenth nerve are tested by the
gag reflex, elicited by stimulating the posterior tongue with a tongue depressor.
8. The tenth cranial (vagus) nerve
 watching movement of the uvula, which normally rises to the midline during
phonation (“ah” reflex).
 If a unilateral lesion is present, the uvula will deviate from the lesion to the
opposite side.
 Hoarseness of the voice and difficulty in swallowing
 Repeated coughing after swallowing liquid, suggest the possibility of vagal
involvement 5/20/2023
Dr. Nathan B.

9. The eleventh cranial (accessory) nerve:
 The patient is asked to keep his shoulders shrugged while the
examiner attempts to push them down.
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147
 The patient is then asked to turn his chin against the examiner’s
resisting hand, first to one side and then to the other.

10. Twelfth cranial (hypoglossal) nerve
 Inspect the patient’s tongue as it lies on the floor of the mouth.
 Then, with the patient’s tongue protruded, look for asymmetry,
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148
atrophy, or deviation from the midline.
 Ask the patient to move the tongue from side to side, and note
the symmetry of the movement
 Ask the patient to push the tongue against the inside of each
cheek in turn as you palpate externally for strength.

The Motor System
149
 The examination of motor function includes evaluation of muscle bulk,
strength, tone, coordination’ and reflexes.
Inspection
 Resting position of the limbs
Resting position of the limbs
 Size
 Symmetry
 Presence of atrophy
 Fasciculations (fine twitching movements) and
 Involuntary movements such as a tremor.
5/20/2023
Dr. Nathan B.

Muscle tone
 Move the limbs passively at every joint while the patient is
completely relaxed.
 Muscle tone may be
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 Normotonic: - found in normal individuals
 Hypotonic: -found in patents with lower motor lesion.
 Hypertonic (spasticity / rigidity):-this may be of different type
e.g. -Clasp knife rigidity
-Cog- Wheel rigidity.

Muscle power
 In the Upper limbs
 Hand Grip- the patient is asked to grip objects while the examiner tries to
remove object from his hand.
 Examine power of each muscle group
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 Examine power of each muscle group
 In the Lower limbs
 Proceed to examine power of each muscle group at every joint by pulling or
pushing in the direction opposite to its action.
 Antigravity muscles are best evaluated by waking on toes, and rising from a
chair without using the hands

152
 Muscle power grading scale
0= no movement
1= flickering of fingers
2= horizontal motion on bed
3= movement against gravity (vertical motion)
4= movement against gravity and partial resistance
5= full power
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153
Deep tender reflexes
Upper limbs:-
 Biceps reflex
Flex arm at the elbow
Place finger firmly on the biceps tendon
Strike your finger with the reflex hammer.
Strike your finger with the reflex hammer.
 Triceps reflex
Support arm and let forearm hang freely
If patient is sitting strike the triceps tendon above
the elbow with the broadside of the hammer
If patient is lying flex the arm at the elbow and
hold close to the chest.
 Brachioradialis
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154
Lower limbs
 Knee jerk reflex
 Have the patient lye down with the knee flexed.
 Strike the patella tendon just below the patella.
 Strike the patella tendon just below the patella.
 Note contraction of the quadriceps and extension of
the knee
 Ankle reflex
 Dorsiflexion of the foot at the ankle
 Strike the Achilles tendon
 Watch and feel for plantar flexion at the ankle.
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155
 Reflexes grading scale
0= Absent
1= Present but diminished
2= Normal
2= Normal
3= Brisk (exaggerated)
4= Exaggerated reflexes with clonus
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Dr. Nathan B.

Superficial reflexes
156
Plantar reflex
 Is tested by scratching the sole of the patient's foot
from the heel toward the toes and observes the
moment of the toes.
 The response could be
 Normal :- downward ( plantar ) flexion of all toes
 Equivocal :- no response
 Up going plantar (Babinisky’s Sign)
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157
The cremasteric reflex:
 is tested by pinching or stroking the skin of the medial
aspect of the thigh. Contraction of the cremasteric
muscle occurs, resulting in elevation of the testis on the
muscle occurs, resulting in elevation of the testis on the
same side.
The superficial abdominal reflex:
 Test the abdominal reflexes by lightly but briskly
stroking each side of the abdomen, above and below
the umbilicus, laterally to medially.
5/20/2023
Dr. Nathan B.

Sensory examination
158
Touch and pressure sensation test
 Light-touch sensation
 Ask the patient to close his eyes.
 Touch the applicator with a light brushing motion to
similar areas on two sides of the body
simultaneously or just one side and ask the patient
to describe the sensation perceived as left, right, or
both sides.
 Pressure test is tested by applying pressure.
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159
 Pain and temperature sensation tests
 Pain sensation is tested with a sterilized pin.
 Temperature tested by using hot and cold test tubes
 Position and vibration sensation tests
 Position and vibration sensation tests
 Position sense is tested by asking the patient to close
eyes, and the examiner moves the patient’s finger or
toe up or down while the patient interprets the action
 Vibratory test needs a tuning fork which is placed
over bony prominences such as the wrist, elbow,
medial malleoli, patellae, etc
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160
 discriminative sensation.
 Sterognosis-identify objects by touching while the
eyes are closed
 Graphstesia-identify numbers or letters written on
the skin surface with eyes closed
the skin surface with eyes closed
 Two point differentiation-identify two closely
approximated stimuli as separate.
 Point localization with the eyes closed
5/20/2023
Dr. Nathan B.

Examination for signs of meningeal irritation
161
1. Neck stiffness- with the patient supine, place your hands
behind the patient’s head and flex the neck forward,
until the chin touches the chest if possible.
2. Kerning’s sign- the thigh is first flexed and then the leg is
extended at the knee while patient is lying on his back.
extended at the knee while patient is lying on his back.
This will stretch the nerve root and pain will be elicited
at the inflamed menings.
3. Brudzinsky’s sign-when trying to flex the neck of patient
with meningeal irritation the knees will automatically flex
to prevent stretching of the menings 5/20/2023
Dr. Nathan B.

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