BSc Clinical Methods I

DR F DERY
CHIEF MEDICAL OFFICER
 Outline

• Introduction to Clinical Methods 4-6

• History taking 7-50
- Adults 7-37
- Children 38-50
• Diagnostic tests (Investigations)51-57
• Physical Examination 58-231
- Medical instruments/devices 58-64
- Introduction to Physical Examination 65-68
- General Examination 69-81
- HEENT (Head, Eye, Ear, Nose Throat) Examination 82-95
- Lymphoglandular Examination 96-103
- Respiratory Examination 104-132
- Cardiovascular Examination 133-162
- Gastro-intestinal (Abdominal) Examination 163-206
- Integumentary Examination 207-231
• Sample history taking/Physical examination 232-238
• Demonstration in Skills Lab) 239-251
• References-252
 Introduction

A patient is a person receiving or registered to receive medical care

A symptom is a phenomenon that is experienced by the

individual affected by the disease- subjective evidence of disease.
A sign is a phenomenon that can be detected by someone other than
the individual affected by the disease- objective evidence of disease.
Clinical features- a group of physical signs or symptoms associated
with a particular morbid process, the interpretation of which leads to
a specific medical diagnosis
Medical diagnosis is the process of determining which disease or
condition explains a person’s symptoms and signs and when
necessary, results of investigations.
Provisional diagnosis- doctors will give a provisional
diagnosis when they are not 100% sure of the diagnosis
Differential diagnosis are various other diseases or
conditions which share signs and/or symptoms of the
diagnosis ie the list of possible conditions that could cause
the same signs and symptoms.
A differential diagnosis occurs when your symptoms match
more than one condition.
Making a diagnosis
Diagnosis should precede treatment whenever possible.
There are several steps in making an accurate diagnosis:
• Gathering information about the patient and creating a
symptom list (Medical history taking- this alone can lead
to a final diagnosis in 76% (60-80%)
• Perform a physical examination- this should yield 20% of
the diagnosis
• Ordering additional tests (to “Rule Out”)
• Review test results and symptoms to generate differential
diagnosis (list of possible causes)
• Prioritize the list by balancing the risk of diagnosis with the
probability
• Make a diagnosis
 History Taking
Adult

The medical history is an account of all medical events and

problems the person has experienced bearing on their health
past, present and future (ASKING FOR SYMPTOMS)
By the end of the history taking you should have a good idea as
to a diagnosis or have several differential diagnosis in mind.
“Always listen to the patient, they might be telling you the
diagnosis”. William Osler
It is usual to record the findings of the history taken under the
following headings (History Taking Format):
• Present illness (PI)
• History of Present illness (HPI)
• Review of other systems (ROS)/Functional enquiry
• Past Illnesses (PI)
• Drug and Allergy History (D&AH)
• Family History (FH)
• Reproductive (RH)/Obstetric and Gynecological History
(O&GH)- any woman of reproductive age
• Immunization History (IH)- in children
• Personal and Social History (PSH)
• Psychological assessment
• Summary of the History taken
• Diagnosis and differential diagnosis
• Suggested Investigations
• Address patient Ideas, Concerns and Expectations
(ICE)
History Taking (Adult)
Introduction
Position self for the interview
• Sit at the same level of the patient at approximately a
meter away from you and not behind a desk
1. Establish rapport

• Greet patient with their title and surname

• Introduce yourself: your name and role
• Confirm patient’s identity (demographic data): name,
age , sex, occupation, religion, address, marital
status, level of education
• Explain reason for the interview- eg I am going to ask
you routine medical questions.
• Seek consent- eg do I have the permission to
continue?
2. Present illness (PI)
• Identify reason for attendance (chief complaint)
• Open questions to identify the patient’s current problem/reason
for attending
• Listen without interruption the opening statement
• Do not engage in detailed questioning at this point- you are
establishing a problem list
• Write down each problem as it is mentioned
• Query whether there are other problems
• Summarize the problem list back to the patient
3. History of present illness (HPI)
Detailed description of chief complaint(s).
• Date of onset- the date the chief complaint started. For example-
apparently well until 2 days ago he developed chest pain
• Mode of onset- sudden or gradual onset
• Course of onset- persistent or intermittent or relapsing and
increasing or decreasing in severity
• Characteristics and location- applicable for description of pain as
chief complaint. Use SOCRATES as a pneumonic
Site- ask about the location of the symptom:
- Where in the chest is the pain?
- Can you point to where you experience the pain?
Onset- speed of onset:
- Did the chest pain come on suddenly or gradually?
- When did the chest pain first start?
- How long have you been experiencing the chest pain?
• Character- ask about specific characteristics of the symptom:
- How would you describe the chest pain? Dull or sharp,
burning or tingling, boring or stabbing?
- Is the chest pain constant or does it come and go?
• Radiation- ask if the symptom moves anywhere else?
- Does the chest pain spread elsewhere?
• Associated symptoms- ask if there are other symptoms
associated with the primary symptom:
- Are there any other symptoms that are seen associated with
the chest pain? (nausea, sweating, shortness of breath etc)
• Timing- clarify how the symptom has changed with time:
- Episodic or continuous? Any change in severity
• Exacerbating and relieving factors- ask if anything makes the
symptom worse or better?
- Does anything make the chest pain worse?
- Does anything make the chest pain better?
• Severity- assess the severity by asking the patient to grade it on a
scale of 1-10
- 1 is the lowest and 10 is the worse symptom you have ever
experienced
However if the present illness is not pain (breathlessness) you may
still use SOCRATES but leave out areas not applicable
For example Site and Radiation cannot be applied in a
complaint of breathlessness. You cannot also grade
Severity of breathlessness from 1-10. In this case it should
be functional. Cannot climb steps, cannot walk a short
distance without being breathless
4. Systemic Enquiry/Functional enquiry
Detailed account of symptoms referrable to each system of
the body. You ask the symptoms as detailed below
• General
- Fatigue/malaise
- Fever/rigors/night sweats
- Weight changes
• HEENT (Head, Eye, Ear, Nose, Throat)
- Head- headache, head injury
- Eyes- pain, blurring of vision, itching, lacrimation,
photophobia, double vision, redness
- Ears- pain, deafness, discharge, vertigo, tinnitus
- Nose- bleeds, discharge, stuffiness, frequent colds,
itching
- Mouth and throat- gum bleeding, sore throat, sore tongue,
dental hygiene, hoarseness of voice, dry mouth, oral thrush
• Lymphoglandular System
- Swelling in the neck, axillae and groin
- Breast lump, nipple discharge, pain, ulceration
- Goiter
- Testicular swelling or pain, descent of testis
• Respiratory symptoms- cough, chest pain, sputum
production, hemoptysis, shortness of breath, stridor,
wheeze
• Cardiovascular symptoms- cough, chest pain, shortness of
breath on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, ankle swelling, claudication, syncope fatigue
• Gastrointestinal symptoms- loss of appetite, abdominal pain,
abdominal distension, nausea, vomiting, diarrhea, constipation,
dysphagia, odynophagia, heart burns, jaundice, hematemesis,
bloody stools, tarry/clay-colored stools.
• Genitourinary symptoms
Urinary tract
- Flank pain, dysuria, nocturia, polyuria, hematuria, change in
urine color, urgency, frequency, hesitancy, dribbling,
incontinence, oliguria, anuria, straining
Genitals
- Males- urethra discharge, testicular pain/swelling,
sores on penis, history of hernia, history of STIs
- Females- vaginal discharge and /or itching, ulcers,
genital prolapse, dyspareunia, menstrual history (age
at menarche, regularity, frequency, duration of
bleeding, amount, LMP, dysmenorrhea,
intermenstrual bleeding, postcoital bleeding), age at
menopause, post menstrual bleeding
• Integumentary symptoms- skin lesions/eruptions,
lumps, skin color changes, ulcers, hair loss, abnormal
hair growth, nail disorders
• Locomotor symptoms- pains, stiffness, swelling,
locking, deformity, weakness, loss of function,
limping
• Obstetrics/gynecology symptoms
- Obstetrics- nausea and vomiting, reduced fetal
movement, vaginal bleeding, abdominal pain, vaginal
discharge, pruritus
- Gynecologic- painful menstruation, irregular vaginal
bleeding, vaginal itching and discharge, dyspareunia, pelvic
pain, trouble getting pregnant, growths/sores/lumps in
vagina area
• Neurological symptoms
- Muscle malfunction- weakness or paralysis, tremors,
seizures or fits
- Changes in sensation- numbness, paresthesia (pins and
needles),tingling, burning sensation
- Changes in conscious level- fainting, confusion, coma
- Changes in special senses- hearing, smell, taste, vision
- Mental ability (cognitive function)- difficulty using
language (aphasia), poor memory, difficulty with
common motor skills (apraxia- eg combing hair), inability
to recognize familiar objects (agnosia), inability to
recognize familiar faces (prosopagnosia), inability to do
simple arithmetic (acalculia)
- Others- slurred speech (dysarthria), vertigo, headache
• Endocrine symptoms
- Local effects- swelling in neck, protrusion of eyes, visual
loss, headache, bone or muscle pain, carpal tunnel
syndrome
- Metabolic effects- polydipsia/thirst,
decreased/increased appetite, polyuria/nocturia,
tiredness, weakness, tremor, palpitation, anxiety
- Skin- hirsutism, skin pigmentation (hypo/hyper-
pigmentation),hair thinning, dry skin, excess sweating
- Body size and shape- short or tall stature, weight loss
or gain
- Reproduction/sex- loss of libido, impotence, infertility,
amenorrhea, oligomenorrhea, galactorrhea,
gynecomastia, delayed puberty, precocious puberty
5. Past Medical Illnesses(PMI)- illnesses in the past
- Previous episodes of the current condition
- Previous hospital admissions
- Past operations, accidents and injuries
- Major illnesses- to ensure none are missed, ask about
these important conditions specifically using the
pneumonic MJ THREADS Ca.
Myocardial infarction, Jaundice, Tuberculosis, Hypertension
Rheumatic fever, Epilepsy, Asthma, Diabetes, Stroke, Cancer
6. Drug and Allergy History (D&AH)
• Prescribed
- All medications that they take and their dose, frequency,
route and compliance
- Recreational drugs- cocaine, marijuana, morphine
- Intravenous (IV) drug use
- Herbal medications that the patient is taking
• Over the counter (OTC) medications
• Allergies- is patient allergic to anything (drugs or
medications)? If allergic to medications, clarify the type
of medication and the exact reaction to the medication
7. Personal and Social History (PSH)
• Alcohol intake
- Alcohol intake- work out number of units per week
Recommended daily intake of 3-4 units for men and 2-3
units for women with 2 alcohol free days per week.
The strength of the alcoholic drink is percentage of
alcohol by volume (%ABV) and is printed on the container
No of units= strength (%ABV) x volume of measure (ml)
1000
Example: one glass (125ml) of 12% wine = (12x125)/1000
= 1500/1000 = 1.5 units
Small shot (25 ml) of 40% vodka= 40x25/1000 =
1000/1000 = 1 unit
1bottle (625ml) of 5% beer= 5x625/1000 =
3125/1000 = 3.125 units
• Tobacco use
Attempt to quantify in pack-years (number of packs of 20
cigarettes smoked per day x number of years of
smoking). Be inclined to double any stated quantities in
both smoking and alcohol intake(Holt’s law)
• Employment history (occupation)- particularly relevant with
exposure to certain pathogens eg asbestos, where you need
to ask whether they have ever been exposed to dust
• Home situation
- House or bungalow
- Any carers
- Activities of daily living (ability to wash, dress and cook)
- Mobility and mobility aids
- Social and family support
- Toilet facilities- pit, KVIP, water-closet
- Water supply- river, well, borehole, pipe-borne
• Travel history
- Travel (recent travel)- infectious diseases related illness
specific to area patient has travelled to. A white man
who recently travelled to Ghana and develops fever is
probably malaria
• Further social history may be required depending on
the type of presenting complaint
- Respiratory presenting complaint- ask about pets, dust
exposure, exposure to the farms, exposure to birds
- Infectious to disease related- ask for a full travel history
8. Family History- gather some disease information
about the patient’s family
- Cause and age of death of parents
- Details of health of children
- Details of health conditions in family- ask about these
conditions using the pneumonic BALD CHASM
Blood pressure (HPT), Arthritis, Lung disease (TB),
Diabetes mellitus, Cancer, Heart disease, Alcoholism,
Stroke, Mental disorders (depression etc)

-
9. Obstetric/gynecological history if a female
- Gravidity and parity
- Complications of pregnancy, labor and puerperium
- Miscarriages and TOP (termination of pregnancy)
- Menstrual history- menarche, duration, cycle, pain,
regularity, LMP (last menstrual period)
- Contraceptive history- methods use, duration of use
- Previous gynecological problems- PID (pelvic
inflammatory disease)
 `
10. Immunization history if a child- all the antigens
Ask for the child health records (weighing card) and
ascertain the immunization status
11. Psychological assessment- ask for orientation in place,
time and person
12. SUMMARY
• Provide a short summary of the history
- Name, age
- Presenting complaints
- Relevant medical history (positives and relevant negatives)
• Give a diagnosis/differential diagnosis
• Explain a brief investigation
• Ask and address patient Ideas, Concerns and
Expectations (ICE)
Ideas
- What does the patient think is causing their
symptoms?
- What is their understanding of the diagnosis?
Concerns
- What are the patient’s concerns regarding their
symptoms and diagnosis?
Expectations
- What is the patient hoping to get out of the consultation?
As a beginner you need to follow the headings of the history
taking (format) but as you gain experience you will know in a
given case which part of the history is particularly worth to
pursue.
When you start with history taking it is wise to make at least
some enquiry under all the headings listed in the format. When
you get more experience you can know which headings to
concentrate on. But in a difficult case it would be unwise to
neglect any of the headings listed.
 Focused History Taking

It is focusing on one main complaint of the patient in history of

present illness, and attempting to collect all related details (solely
to the complaint) in other parts of the history format.
Usually such focused history is required when seeing patients in the
OPD or in an emergency department.
- Present illness, history of present illness- is the same as the
comprehensive history taking
- Systemic Review/Functional Enquiry- only systems involved in
the present illness and history of present illness are reviewed
Example- chest pain- the following systems give chest pain-CVS, RS,
GIT (because of GERD). You only need to review these systems in
chest pain. The rest of the other systems are left out
• PMI- ask if patient has any medical conditions
• Drug and Allergy
- Ask if currently on any prescribed medication or OTC
- Ask if patient has any allergies
• FH
- Ask if any family history of diseases associated with
the symptom (eg chest pain)
- Ask if close relatives are deceased and cause due to
the presenting symptom
• Personal and Social history
- Explore patient social history and potential risk factors
for medical conditions which could present with the
symptom
- Example chest pain- smoking, alcohol, recreational drugs
increase risk of cardiovascular disease (angina, MI)
• Summary of history- summary of key points
• Diagnosis/differential diagnosis
• Suggested investigations
• Ask patient for his ideas, concerns and expectations of
the symptom (ICE) and address them
 History Taking (Pediatrics)

• Put child at ease by:

- Compliment their clothes or show an interesting toy. Let them
play with your stethoscope, playing peek-a-boo. This is to
distract them
- Tell child your name, role and ask theirs.
- Shake hands with them, confirm patient details- age, date of
birth (DOB)
- Gain consent to take history
• Talk to the parents- Ask for the infant record book- contains
information about weight, immunization, development and
illnesses in first few years of life
Pediatric History Format:
1. Present illness
- Symptoms and duration. Use parents own words
2. History of present illness
To gain more details these are useful questions
- When did the current problem start?
- Has the problem changed with time and what way?
- Have there been similar episodes in the past?
- Does anything seem to make the problem better or worse?
- Use SOCRATES if pain is the present illness
3. Functional Enquiry/Review of Systems (ROS)
- General (Systemic)- fever recently, weight change, dietary
and fluid intake, increase crying, reduce activity
- Respiratory System- cough, recent running nose wheeze,
labored breathing, sore throat, earache, frequent chest
infections
- Cardiovascular System- shortness of breath on exertion,
edema, chest pain, shortness of breath/sweating on
feeding, squatting, cyanosis, fainting
- Gastrointestinal- abdominal pain, vomiting, diarrhea or
constipation, blood in stool
- Genitourinary System- dysuria, frequency, nocturia,
urine output, hematuria, incontinence, enuresis
(bedwetting)
- Nervous System- fits, headache, visual problems,
numbness, weakness, incontinence, frequent falls
- Musculoskeletal System- limp, joint swelling,
movement dysfunction
- Skin- hair loss, rash (location and spread), mouth
ulcers, sore eyes, cold limbs
4 Birth history
• Antenatal
- Were there any obstetric problems?
- Were any medications or x-rays taken during pregnancy?
• Delivery (Natal)
- Were there any concerns during delivery or any interventions
required?
- What was the child’s gestation and weight?
• Post-natal
- Did the child require admission into NICU, and if so for what
reason?
5. Feeding
- Is child breast-fed or bottled-fed?
- Is the child on supplements or special dietary requirements
- At what age was the child weaned?
6. Immunizations- ask for the infant record book (weighing
card). Is child up to date with their immunizations?
7. Developmental History
- Is the child meeting their developmental milestones? They
include: Gross motor, fine motor, language and social.
- Are there concerns about the child development?
8. Past Medical and surgical History
- Significant illness in the past or previous surgeries?
- History of similar complaints in the past
9. Drugs and allergies (D&AH)
- Is child currently on prescribed or over-the-counter
medications?
- Any known allergies?

10. Family History (FH)

- Ask if any family members/friends have recently experienced
similar symptoms to those the child is presenting with
- Ask about conditions which appear to run in the
family
11. Social history
• Relationship status of parents/carers
• Type of accommodation, number of persons in room,
any carers?
• Child’s preferred play
• Any schooling issues?
• Smoking status of parents
If an adolescent or young adult, it is important to address the health
risk behaviors by using the acronym “HEEADSSS”
• Home and relationships
- Who lives at home with you?
- Do you have your own room
- Who do you turn to when you are feeling down?
• Education and Employment
- Are you in school at the moment?
- Which year are you in?
- How are you doing at school?
- What do you want to do when you finish school?
- Do you have friends at school?
• Eating
- Have you noticed any change in your weight recently?
- Have you been on diet?
• Activities and hobbies
- How do you spend your spare time?
- What do you do to relax?
- What kind of physical activities do you do?
• Drugs, alcohol and tobacco
- Does anyone smoke at home?
- Have you been offered cigarettes? How many do you smoke each
day?
- Have you been offered alcohol? How much and how often?
- Have you tried cannabis? How much and how often?
- Have you tried drugs
• Sex and relationships
- Have you ever had sex?
- What contraception do you use?
• Self harm, depression and self-image
- How is life going in general?
- What do you do when you feel stressed?
- Do you ever feel sad and tearful?
- Do you think about hurting or killing yourself?
- Do you ever tried to harm yourself?
• Safety and abuse
- Do you feel safe at school/home?
- Is anyone harming you?
- Is anyone making you do things that you don’t want
to?
 Developmental Assessment
Delay in all 4 areas is usually abnormal, but delay in 1 area may not be.
Assess the child according to the age
Age Gross motor Fine motor language Social
3mths Head control Opens hand laughs Smiles(6weeks)
6mths Sits Palmar grasp, reaches, Babbles-ba, Eats solid food
transfers da, ka
9mths Crawls, pulls to Begin to develop Double babble- Waves bye-bye
stand pincer grip dada, baba
12mths Walks Developed pincer grip Mummy, daddy Peek-a-boo (hides
(hold with thumb and 1st finger) face and pops back)

18mths Walks upstairs, Scribbles, 3 block 2-word phrases Mimics

jumps tower
2yrs Kicks, runs Draws straight lines Begin to use clauses Uses spoon,
undresses
3yrs Hops, walks up Draws a circle Says name Dresses, has a
stairs friend
4yrs Stands on one leg Draws a cross Sentences of5+words Does up buttons

5yrs Can ride bicycle Draws a triangle Ties shoe laces

 Medical Investigations/Tests (Diagnostic Tests)

Diagnostic tests are any type of medical tests carried out to diagnose
a condition, disease or illness in people who are displaying specific
signs of possible illness
Tests are done for a variety of reasons:
• Screening- are carried out to detect early disease or risk factors in
seemingly healthy individuals who are not displaying any
symptoms
• Confirm a suspected diagnosis
• Excluding something important
• Evaluating the severity of a disease
• Monitoring the progress of the disease
• Monitoring the response to treatment
Types of Investigations
1. Analysis of body fluids
• Blood
- Complete/full blood count (CBC/FBC)- analyses 15 different
blood test readings (automated) that provide a general
overview of an individual’s health and is often the first test
used to determine if a patient has an infection or other factors
are causing their symptoms
- Comprehensive metabolic panel (CMP)- is a 14 blood analysis
which include kidney and liver function, electrolytes, protein,
blood glucose and acidity/alkalinity
• Urine
- Microscopy- allows identification of bacteria and other
microorganisms, urinary casts, crystals and cells
- Culture and sensitivity- determine the growth of organisms and
antibiotic sensitivities
• Pleural and ascitic fluids
- Microscopy , culture and sensitivity
- Cytology- for malignant cells
- Biochemistry- protein, glucose, amylase
• Cerebrospinal fluid (CSF)
- Appearance
- Microscopy
- Biochemistry
• Stool- for appearance, microscopy and biochemistry
2. Medical Imaging- show structures inside the body in great detail
• X-rays- record images that show variations in tissue density. Evaluate
issues in arms, legs, chest, spine and abdomen
• Computed tomography (CT)- more advanced and detailed version of
x-rays used to produce cross-sectional images of bones, soft tissues,
blood vessels and other internal organs. They are crucial in
diagnosing internal injuries, fractures and tumor growth
• Magnetic resonance imaging (MRI)- uses magnetic and radio waves to
produce highly detailed images of organs, soft tissues, bones and
other internal organs without use of radiation. Preferred method in
detecting abnormalities in the brain and spinal cord
• Ultrasonography (USG)- use of high-frequency sound waves to
project images of internal organs, tissues and vessels
• Nuclear medicine imaging- Positron Emission Tomography
(PET)
3. Endoscopy- a procedure which uses specialized instruments
to examine the internal organs and vessels using a flexible
tube with light and camera attached to it (endoscope). They
include:
• Upper GIT endoscopy, colonoscopy, sigmoidoscopy,
bronchoscopy, cystoscopy, enteroscopy, arthroscopy,
hysteroscopy, laryngoscopy, laparoscopy etc
4. Measurement of body functions
- Electrocardiography (ECG)- electrical activity of the heart
- Echocardiography- use of sound waves to produce heart
images
- Electroencephalography (EEG)-electrical activity of the
brain
- Spirometry, peak expiratory flow rate- lung function tests
5. Biopsy- tissue samples are removed and examined, usually
with a microscope
6. Genetic Testing-analysis of genetic materials from cells of
the skin, blood, bone marrow for:
- Abnormalities of genes (including DNA)
- Abnormalities of chromosomes
Take note of the following:
• Only do a test/investigation if the result will influence
management of the disease
• Do not interpret lab results except in the light of clinical
assessment
• If there is disparity , trust clinical judgment and repeat the
test
• Request an investigation if you can interpret the results. If you
cannot interpret the results refer the patient to a higher level
 Physical Examination

Physical examination is the evaluation of the body to

determine its state of health (LOOKING FOR SIGNS)
Physical examination is the chance to confirm or refute the
symptoms in the history.
Instruments/Devices to aid in Examination
We need instruments/devices to aid us in the examination
• Clinical Thermometer- for measuring temperature
Most commonly used types
- Digital thermometer- can be used in the mouth, rectum
or armpit
 Physical Examination

- Digital ear (tympanic) thermometer

- Forehead (non-contact) thermometer
- Mercury (liquid in glass) thermometer
• Sphygmomanometer- for measuring blood pressure
Types:
- Mercury sphygmomanometer
- Aneroid (without fluid) sphygmomanometer
- Automatic digital sphygmomanometer
• Stethoscope- for listening to body sounds- heart,
lungs, thyroid, intestines as well as flow in arteries
and veins
Types
- Traditional acoustic stethoscope with different
models
- Electronic (digital) stethoscope
- Stethoscope for hearing impaired
• Otoscope- to view ear canal and the tympanic
membrane
• Ophthalmoscope- to examine the interior structures of the eye-
retina, optic disk and blood vessels
• Percussion(patella) hammer- used to test deep tendon reflexes.
There are 4 common types
- Taylor hammer- triangular rubber head with solid handle
- Buck hammer- cylindrical rubber head with solid handle to
middle of head
- Queen’s square hammer- circular rubber head, nylon handle
with pointed tip sticking out from the centre of the circular
head
- Babinski hammer- same as the Queen’s but handle is attached
to the side of the circular head
• Disposable/safety pin- for pain sensation
• Brush/cotton wisp or microfilament- light touch sensation
• Penlight- provides light to examine specific area of the body
• Nasal speculum- for inspection of the lining of the nose,
nasal membranes and septum
• Laryngeal mirror- to examine larynx and other areas of the
throat
• Audioscope- used to screen for hearing loss
• Tuning fork- to test patient hearing (air and bone
conduction) and vibration sensation
• The examiner’s hand( see methods of palpation)
Methods of Palpation
- Finger tips- for skin texture(smooth, rough), swelling,
pulsations (checking pulse)
- Fingers and thumb (grasping action)- to determine position,
size and consistency of body part
- Front of the fingers- for light palpation, deep palpation, light
ballottement and deep ballottement
- Back of fingers and hand-to check body temperature
- Side of hand (palmar)- to check (feel for) vibrations in the
body- vocal fremitus (vibration of sound), fluid thrill (vibration
of fluid in abdomen), heart thrill (vibrations of the valves)
 Areas that are Commonly Auscultated
• Respiratory system (lungs)- listen for normal breath sounds
and abnormal breath sounds
• Heart- listen for normal and abnormal heart sounds
(murmurs)- caused by turbulent blood flow through the
heart valves
• Abdomen- listen for normal and abnormal bowel sounds
• Major vessels (carotid artery, abdominal aorta, renal
artery)- for bruits (an audible vascular sound associated
with turbulent blood flow)
• Thyroid gland- for bruits
Introduction to Physical Examination
• To begin (WIPER)- for all systems examination
- Wash your hands/sanitize hands
- Introduce self- name and status
- Permission- explain what you would like to do and
obtain consent
- Expose- expose the relevant part ensuring as much
privacy as possible
- Reposition the patient appropriately
• During examination
Follow a standard order (Format) for each system:
- Inspection (looking with your eyes)
- Palpation (feeling with fingers/palm)
- Percussion (tapping on middle finger with middle
finger) over a body part
- Auscultation (listening with stethoscope)
EXCEPT for assessing the abdomen the format might
change: inspect, auscultate, percuss, palpate (to avoid
altering bowel sounds)
• End of examination
- Consider the need to reexamine any system in more depth

- Reexamine any aspect you are unsure about

- Inform patient you have completed
- Thank the patient
NB: Before commencing a physical examination:
• Ensure that you have a chaperone present (health care
professional) and should be same sex as patient
• Always stand at the patient right hand side
• Ask for pain
Examination of the various systems of the body. They include:
- HEENT (Head, Eyes, Ears, Nose, Throat)
- Lymphoglandular system
- Respiratory system
- Cardiovascular system
- Gastrointestinal system
- Integumentary system (skin, hair, nail)
- Genitourinary system
- Nervous system
- Musculoskeletal system
- Endocrine system
General Examination
This cuts across all the Systems
Exposure of patient is from chest to waist
Check Vital Signs
• Temperature
- Normal (oral- 36.8; rectal- 37.3; axillary- 36.4)
- Fever- morning temperature >37.3 (oral) or 37.7 (rectal)
- Hypothermia (low temp)- core (rectal) temperature
<35)- cold exposure (near drowning), excess alcohol,
drug overdose, myxedema
• Pulse rate (commonly palpated- radial, brachial, carotid,
femoral, popliteal, posterior tibial, dorsalis pedis). For
examination of pulses see cardiovascular system
- Express pulse in beats per minute. Count for 1 full
minute and not 30 secs x 2 or 15 secs x 4
- Normal rate is 60-90bpm. <60bpm is bradycardia,
>100bpm is tachycardia
• Respiratory rate- count the breathing in and the
breathing out as 1 cycle
- Normal rate at rest 12-18 breaths per minute
• Blood Pressure (BP)
- Use the right cuff for the right patient- we have child,
standard adult and large adult cuffs
- Normal- 120-129/80-84
• Blood Glucose
- Fasting blood glucose (FBS)- 3.6-5.6mmol/L
• General appearance- stand at foot end of bed
- Oriented in place, person and time?
- Acutely or chronically ill looking?
- In pain? Does it make him lie still (peritonitis) or writhe
about (colic)
• Pattern of breathing
- Fast, deep breaths- anxiety
- Prolonged expiratory phase- asthma, COPD
- Kussmaul’s breathing (fast, deep and labored breathing)-
metabolic acidosis
- Cheyne stokes (alternating periods of cessation of
respiration and hyperventilation)- heart failure, stroke,
brain tumors
• Shape- obese, cachetic, normal for his/her age
• Abnormal body hair distribution- bearded female or
hairless male is suggestive of endocrine disease
Feet
• Look for varicose veins (dilated engorged veins in the
legs)
• Pedal swelling
- Pitting- press gently on both legs above the medial
malleoli with both thumbs for a while and see/feel if
a dent- severe cardiac/renal failure, nephrotic
syndrome, severe malnutrition
- Non-pitting- lymphedema
Then move up and hold the hand
Palm
• Warm, sweaty hands- hyperthyroidism.
Cold, moist hands-anxiety
• Palmar erythema (reddish base of palms)- cirrhosis of liver,
pregnancy, polycythemia
• Dupuytren’s contracture (fibrosis and contracture of
palmar fascia)- liver disease, epilepsy, trauma, ageing
• Check for palmar pallor (palmar skin creases color)-
compare yours with the patient and state no pallor, some
pallor or severe pallor- anemia, emotional shock
Dorsum of hand
• Hydration status (dehydration)
- Skin turgor- pinch back of hand and see if the skin goes
back slowly/very slowly- dehydration or lack of connective
tissue support in ageing
Nails
• Check for peripheral cyanosis- (finger nails are bluish)-
vasoconstriction and peripheral vascular disease, reduced
cardiac output, exposure to cold
• Check for choilonykia (spoon shaped nails- concave
indentation)-iron deficiency anemia.
• Leukonychia (white discoloration of nail)- low albumin, chronic
ill-health
• Check for pitting (tiny indentations in the surface of the nail)-
psoriasis, alopecia areata
• Onycholysis (premature lifting of nail)- hyperthyroidism, fungal
nail infection, psoriasis
• Splinter hemorrhages (fine longitudinal bleeds under nails)-
infective endocarditis in a febrile patient
• Beau’s lines (transverse nail depressions)- arrested nail growth
during a period of acute severe illness
• Paronychia- infection of skin adjacent to the nail
• Check for clubbing (increase curvature of nails)
- Schamroth’s sign-diamond shaped window seen between opposed
nail beds is lost
- Lovibond angle- raise the finger to level of your eye to see if the
angle between the nail and nail bed is obliterate
Finger joints
• Heberden’s nodes (bony overgrowth/swelling at DIP joint)-
osteoarthritis
• Bouchard’s nodes (bony overgrowth/swelling at PIP joint)-
osteoarthritis
• Swan neck deformity (fixed flexion at DIP joint and extension at PIP
joint)- rheumatoid arthritis
• Boutonniere deformity (fixed extension at DIP joint and flexion at PIP
joint)- rheumatoid arthritis
Then move up to the head and neck
• Check and measure JVP (Jugular Venous Pressure)- with
patient lying back with neck exposed and head turn to
left. For measurement see cardiovascular system
examination
• Hepatojugular or abdominojugular reflux/test- exert
pressure over the liver with your right palm and the JVP
will rise> 4cm- constrictive pericarditis, RHF, restrictive
cardiomyopathy
• Kussmaul’s sign- JVP rise during inspiration- pericardial
constriction, right ventricular infarction
• Check for jaundice- stabilize the upper eye lid with one
finger and let patient look at the other palm as you move
it towards the abdomen and vice versa. This exposes the
white of the eye for you to see if it is yellow.
- The sign of jaundice is yellow skin and sclera seen in good
light- hepatitis, hemolysis, chronic liver disease, gall stones
- Yellow skin alone is unreliable, it is produced by uremia,
carotenemia, pernicious anemia. Note that in these cases
the sclera is spared
• Check for conjunctiva pallor- let patient look up and gently
draw down the lower eyelid with a thumb
• Let patient open mouth and check for:
- Central cyanosis(bluish tongue and lips)- COPD,
pulmonary embolism, pneumonia, congenial heart
disease
- Dehydration(dryness)
- Pallor on the protruded tongue
• Palpate for enlarged lymph nodes (normal nodes are
not palpable). For examination of the lymph nodes
see lymphoglandular system examination
• Body Mass Index
The body mass index (BMI) is a useful estimate for
body fatness
BMI = Weight (kg)/[height (m)] square
The BMI is classified as follows:
- 19-25 = normal
- 25-30 = overweight
- 30-40 = obese
- > 40 = extreme or morbid obesity
 Physical Examination of Systems
HEENT (Head, Eyes, Ears, Nose, Mouth and Throat)

Presenting Symptoms (Ear)

• Otalgia (ear ache)- use SOCRATES to assess the pain
Causes- acute otitis externa/media, neoplasm, trauma
• Otorrhea- discharge from the external auditory meatus
- watery- eczema, CSF
- Purulent- acute otitis externa
- Mucoid- chronic suppurative otitis with perforation
- Blood-stained- trauma, cancer
• Hearing loss- total loss is unusual
- Conductive hearing loss- wax, middle ear effusion, chronic
middle ear infection
- Sensorineural (disease in cochlea/neural pathway)-
noise exposure, ototoxicity, mumps, meningitis
• Tinnitus- perception of abnormal noise in the ear
- Rushing, hissing or buzzing tinnitus- usually associated
with hearing loss- due to pathology in the inner ear,
brainstem or auditory cortex
- Pulsatile tinnitus- noise transmitted from blood vessels
close to the ear- arterial aneurysms
- Cracking and popping noises- dysfunction of the
eustachian tube or myoclonus of muscle in middle ear
• Dizziness- ototoxic drugs, middle ear infections,
otosclerosis
Presenting Symptoms (Nose)
• Nasal obstruction (blocked nose)
- Constant- nasal polyps, enlarged turbinates
- Intermittent- allergic rhinitis, common cold
• Nasal discharge
- Watery/mucoid- allergic or infective (viral)
- Purulent- infective or foreign body
- Blood stained- trauma, tumor, bleeding disorder
• Epistaxis (nose bleed)
- Trauma- from nose picking or infection
- Prolonged bleeding- hypertension, alcohol,
coagulation defects, anticoagulants, neoplasms and
angiomas
• Sneezing- commonly associated with rhinorrhea and
itching of nose and eyes- allergic rhinitis, viral URTI
• Disorders of smell
- Anosmia (loss of smell)- nasal polyp, head injury
disrupting olfactory nerve
Presenting Symptoms (Mouth and Throat)
• Oral pain- dental caries, gum disease
• Throat pain (sore throat)- acute tonsillitis (associated with fever),
viral (associated with rhinorrhea and cough), malignancy (chronic
cases)
• Halitosis (offensive- smelling breath)- poor dental hygiene,
gingivitis, tonsillitis, chronic sinusitis
• Dysphonia- alteration in quality of voice
- Inflammatory- acute/chronic laryngitis
- Neoplastic- laryngeal cancer
- Nervous- recurrent laryngeal nerve palsy
• Lumps in the mouth
Presenting Symptoms (Eye)
• Symptoms you can feel- pain , irritation, eye strain
• Changes in function- watery eyes (epiphora)
• Changes in appearance of eye- sclera icterus, red eye,
miosis (too narrow pupils)
• Changes in how you see- diplopia , blurred vision
• Changes in eye alignment
- Exotropia- when one or both eyes look outwards
- Esotropia- one eye deviated inward
 Physical Examination

1. Head
• Hair
- Recession of hair at forehead margin or temporal recession is
in favor of male type distribution
- Thin, sparse hair in hyperthyroidism
- Coarse, brittle hair in hypothyroidism
• Scalp
- Contact scratching with crusting and oozing- pendiculus capitis.
Lice resemble grains of wild rice loosely attached to hair
- Patches of thinned and broken scalp hair with crusting and
inflamed scalp- fungal infection (tinea capitis)
- Crusted and oozy yellow patches scattered on scalp with
unpleasant odor and neck lymphadenopathy- bacterial infection
- Patchy, diffuse, yellowish, greasy itching scales involving scalp-
seborrheic dermatitis
• Skull- any deformities, depression, masses or tenderness
2. Eye
• Visual acuity- see cranial nerves examination
• Visual field- see cranial nerves examination
• Eyelid
- Look for edema
- Inflammation of eyelids along lid margins with crusts/scales-
blepharitis
- Failure of eyelids to close- facial nerve palsy
• Conjunctiva and sclera
Let patient look up and gently draw down the lower eyelid
with a thumb
- Look for conjunctival pallor, hemorrhages, trachomatous
changes, pterygium
Stabilize the upper eye lid with one finger and let patient look
at the other palm as you move it towards the abdomen and
vice versa
- Look for jaundice
• Lens- inspect cornea for opacities with oblique lighting
• Pupils- inspect size, shape and symmetry of pupils
- Constriction- myosis, dilation- mydriasis
• Lid lag, lid retraction, proptosis, ptosis
Let patient follow examiner’s finger as he moves his
fingers downwards
- Lid lag- upper eyelid lags behind the eyeball- Grave’s
disease
- Proptosis- forward displacement of eyeball- Grave’s
disease
- Ptosis- drooping of upper eyelid
3. Ear
- Inspect for size, shape and deformity
- Check tragus tenderness- tenderness while pulling the tragus-
middle ear infection
- Hot, tender postauricular swelling- mastoiditis
Otoscopic Examination
- Gently retract the pinna backwards and upwards to straighten
the external meatus. Place the otoscope into the external ear
- Light is reflected from an intact membrane
- Visualize, ear discharge, impacted wax and membrane
perforation
4. Nose
• Inspect the nose from the front, side and back
• Inspect intranasal contents by gently pushing the tip
of the nose upwards with a finger and aid of light
• Inspect nasal cavity with nasal speculum or an
otoscope
• Look for nasal blockage, nasal polyps, nasal septum
deviation and perforation
• Percuss over paranasal sinuses- clinically accessible
sinuses (frontal, maxillary and ethmoid)
- Frontal sinus- tap with finger tip over the frontal
region above both eyes for tenderness
- Maxillary sinus- tapping below both eyes for any
tenderness
- Ethmoid sinus- tap over sides of nose on both sides
just below the inner canthus
5. Mouth and Throat
• Mouth odor
- Halitosis (bad mouth odor)- poor dental hygiene,
suppurative lung disease, PUD
- Fetor hepaticus (fruity mouth odor)- hepatic
encephalopathy
- Uremic fetor (urine mouth odor)- uremia
- Acetone breath- diabetic ketoacidosis
• Lip- look for ulcers, cracks
• Gingiva- gum bleeds, lead lines, ulcer
• Tongue- coating, fissures, atrophy of papillae. Whitish
tongue coating with erythematous base on scraping with
spatula- candidiasis
• Buccal mucosa and palate- ulcers, patches and masses
• Nasopharynx-note tonsillar exudates, ulcers, masses
LYMPHOGLANDULAR SYSTEM
Presenting Symptoms
- Enlarged lymph nodes
- Breasts- lumps, pain
- Nipple discharge, ulcerations
- Swelling in front of neck- goiter
- Descent of testes
Lymph Nodes
- Head and Neck nodes- stand behind patient in an
upright posture and using fingers of both hands-
check posterior triangle, jugular chain (anterior
triangle), submandibular, sub-mental, pre-and post
auricular, supraclavicular and occipital regions
Left supraclavicular lymph node (Virchow’s node)- its
enlargement is one of the first clinical signs of
metastatic intraabdominal malignancy (gastric cancer).
This is called the Troisier’s sign
- Axillae- with patient sitting stand at right side and support
the abducted right arm with your right hand and use your
left to examine the axilla and vice versa for the left axilla.
Feel for the lateral, pectoral, subscapular, central and
infra-clavicular nodes
- Epitrochlear- put palm of right hand under the flexed
right elbow and feel with your fingers for the nodes in the
groove above and posterior to the medial epicondyle
- Inguinal- with patient lying supine palpate for the
horizontal chain (just below the inguinal ligament) and
the vertical chain (runs along the saphenous vein)
- Popliteal- partially flex knee and feel the popliteal
fossa
- Liver and spleen- should be examined in the presence
of generalized lymphadenopathy
- Enlarged lymph nodes:
o Unusually firm/hard- malignancy
o Painful and tender- infection
o Fixed to surrounding tissues- malignancy
o Matted together- tuberculosis
o Red and swollen overlying skin- inflamed nodes
Thyroid Gland
• Inspection
- Inspect the neck from the front
- Look for thyroid gland while patient swallows a sip of water
- The thyroid gland moves up on swallowing
Thyroglossal cyst moves up on protruding the tongue
• Palpation
- Patient in sitting position, palpate from behind
- Put fingers of both hands over the enlarged lobes
- Feel for tenderness, consistency, nodularity, surface
- For enlarged cervical and supraclavicular nodes
• Percussion
- Percuss anterior chest wall over the sternum
- Dull to percussion over sternum occurs in retrosternal goiter
- Elicit Pumberton’s sign- ask patient to lift the arms over the
head and wait for 1 minute. Development of cyanosis,
inspiratory stridor and non-pulsatile elevation of the JVP due
to compression of the superior vena cava by retrosternal
goiter at the thoracic inlet
• Auscultation
- Put stethoscope over goiter and listen for bruits- diffuse
goiter due to Grave’s disease
Breast
• Inspection
Patient in sitting position with arms at her sides
- Look for size, symmetry and contour
- Look for size and shape of nipples
- Look for skin ulceration, discharge and retraction
Ask patient to sit and raise her arms over the head
- Look for dimpling or retraction, note welling in axilla
• Palpation
Patient sitting with both arms at sides, leaning forward and then
arms above the head
- Palpate upper outer quadrant, lower outer quadrant, lower inner
and upper quadrants in rotation and last the nipple and
subareolar region with pulps of fingers for discrete, hard lumps
- Check for consistency, tenderness, dimpling, retraction, lump or
mass
- If you detect any lump- check for size, shape (regular, irregular),
mobility in relation to skin and underlying muscle, tenderness,
well circumscribed or not, skin changes (dimpling, peau d’ornge)
- Compress the areola- watch for discharge (blood- ductal
papilloma; yellow serous- fibro-adenoma; serous fluid- early
pregnancy; milky- lactation)
 Respiratory System

Presenting symptoms
• Cough
- Duration- chronic cough (>3 weeks)- COPD, lung cancer,
bronchiectasis, tuberculosis. Acute cough (< 3weeks)-
common cold, pneumonia, acute bronchitis
• Sputum production- ask for color, consistency and amount.
Main types of sputum color
- Serous (watery/pink)- pulmonary edema
- Mucoid (clear, grey)- asthma, chronic bronchitis
- Purulent (yellow/green)- bronchiectasis, lung abscess
- Rusty (red)- pneumococcal pneumonia
• Hemoptysis (coughing up blood)- bronchiectasis, lung cancer,
pulmonary embolus, pulmonary infarction, tuberculosis
• Dyspnea (shortness of breath)- uncomfortable awareness of
breathing
- Sudden onset with chest pain- pneumonia, pulmonary
embolism, rib fracture
• Wheeze- a continuous whistling sound heard with unaided ear
during breathing- asthma, chronic bronchitis, foreign bodies
• Chest pain- originate from injured pleura, chest wall and
mediastinal structures
- Explore fully by the use of SOCRATES.
- Pleuritic chest pain- is sharp and stabbing, worse by deep
breathing and coughing- pneumonia, pneumothorax,
fractured ribs, pulmonary embolism
- Chest wall pain- will be tender to touch over the
corresponding chest wall- intercostal muscle injury,
invasion of chest wall by lung cancer
• Stridor- a harsh crowing inspiratory sound heard-
laryngitis, croup
• Associated symptoms- fever, cyanosis, fatigue, anorexia,
diaphoresis (sweating), weight loss
Physical Examination
• Peripheral examination
At end of bed
- Look for signs of breathlessness or respiratory distress
Hands
- Look for clubbing
Schamroth’s sign-diamond shaped window seen between
opposed nail beds is lost
Lovibond angle- raise the finger to level of your eye to see if the
angle between the nail and nail bed is obliterate
- Look for tar staining and peripheral cyanosis (blue nails)
- Examine for flapping tremor (asterixis)- flapping (like wings
of bird) when holding the hands dorsiflexed with the
fingers abducted- Late sign of carbon dioxide retention in
type 2 respiratory failure (COPD), chronic liver disease,
chronic kidney failure
Face
- Check conjunctiva for pallor (anemia)- let patient look up
and gently draw down the lower eyelid with a thumb
- Lips and tongue for central cyanosis (bluish color)
- Palpate the cervical, supraclavicular and axillary lymph
nodes
Examine sputum if available
- Consistently large volumes- bronchiectasis
- Sudden increase in volume- rupture of abscess or
empyema or cyst into a bronchus
- Serous (watery/pink)- pulmonary edema
- Mucoid (clear, grey)- asthma, chronic bronchitis,
smoking
- Purulent (yellow/green)- bronchiectasis, lung abscess
- Rusty (red)- pneumococcal pneumonia
• Examination of the Chest
Expose the chest up to umbilicus
Inspection
- Look for chest wall deformities- barrel chest (COPD,
asthma), pectus excavatum (no significance), carinatum
(asthma, rickets), scoliosis (birth defect), kyphosis
(osteoporosis, arthritis), Lordosis (congenital, osteoporosis)
- Look for asymmetry of chest wall movement
- Note patterns of breathing
o Tachypnea (rapid shallow breathing)- RR >20bpm- severe
pneumonia
o Bradypnea (slow breathing)- RR < 8bpm- barbiturate
poisoning
o Kussmaul’s breathing (fast, deep and labored
breathing)- metabolic acidosis
o Cheyne stokes (alternating periods of cessation of
respiration and hyperventilation)- heart failure,
stroke, brain tumors
o Paradoxical breathing (abdomen sucks inwards with
inspiration)- diaphragmatic paralysis
Signs of respiratory distress
o Tachypnea- RR >20bpm
o Flaring alae nasi
o Use of accessory muscles of respiration
(sternomastoid, platysma)
o Supraclavicular/intercostal/subcostal retraction
- Observe chest wall movement
o Decrease movement indicate lung disease on that
side. An objective measure of chest movement is
chest expansion which is under palpation
Palpation
• Assess for chest wall tenderness- look at face of patient while
palpating
• Assess for presence of subcutaneous emphysema- crackling
sensation on palpating over gas-containing chest wall
• Assess for symmetry of chest wall expansion
- Patient to lie flat during the examination
- Put both hands on the patient’s chest, just below the level of the
nipples and anchor the fingers laterally at the sides
- Extend the thumbs so that they touch in the midline
- Ask the patient to take a deep breath and watch the thumbs
move apart equally
o Normal chest expansion- 4-5cm
o Reduced chest expansion on one side- localized lung
fibrosis, lung collapse, pleural effusion, pneumothorax
o Symmetrically reduced both sides- emphysema, diffuse
fibrotic lung disease
• Trachea position
- Place your index and ring fingers on the prominences of
the sternoclavicular joints
- Use the middle finger of the same hand to trace the
trachea from the voice box to the sternal notch and note
whether it is deviated to the left or right
o Deviation towards side of lung lesion- upper lobe fibrosis,
upper lung collapse, pneumonectomy
o Deviation away from side of lung lesion- massive pleural
effusion, tension pneumothorax
• Tracheal tug- when finger resting on the trachea feels it
move inferiorly with each inspiration- hyperinflation of
chest (tracheobronchial obstruction)
• Tactile fremitus
- Ask patient to say 999 whilst palpating the chest wall with
your open palm over different respiratory segments &
comparing both sides.
- Reduced tactile fremitus- lung collapse, pneumothorax,
hydrothorax, lung fibrosis
- Increased tactile fremitus- lung consolidation (pneumonia)
Percussion
- Place left hand on chest with fingers separated and flat
- Press left middle finger firmly against the chest and strike
its middle phalanx with the flexed right middle finger
- Comparing both sides of the chest step by step
- Percuss directly over the clavicle for the apex of the lungs.
- Percuss symmetrical areas of anterior, posterior & axillary
regions (3-4 different locations bilaterally)
Types of percussion note
• Resonant- normal lung sound
• Dullness- increased tissue density
- Lung collapse, consolidation (pneumonia), fibrosis, tumors,
lobectomy, pleural thickening.
- Dullness over the heart(cardiac dullness) and liver(liver
dullness) are normal.
If Resonance over the liver & heart:
- Overexpansion of the lungs eg asthma,
emphysema - Bowel perforation
with gas under the diaphragm.
• Stony dullness- pleural effusion
• Hyper-resonant- decreased tissue density
- Pneumothorax , COPD
Auscultation
Listen with the diaphragm of the stethoscope over symmetrical
areas of the anterior, posterior, & axilla & the bell over the
supraclavicular fossa and comparing both sides of the chest step
by step
Breath sounds
• Normal (Vesicular)- quiet and gentle
• Bronchial (loud, hash and hollow blowing quality, similar to
auscultating over trachea)- lung tissue has become firm or solid
eg consolidation, fibrosis
• Diminished
- Local- effusions, tumor, pneumonia, lung collapse,
pneumothorax
- Global- COPD, asthma
• Silent chest- life threatening asthma due to severe
bronchospasm preventing adequate air entry
Added (adventitious) Sounds
• Rhonchi (wheeze heard with stethoscope)- musical sound
heard on expiration eg asthma, COPD, foreign body, cancer
• Crepitations (crackles, rales). Like dragging a packing case
on a floor
- Fine & high pitched-pulmonary edema
- Coarse & low pitched-pneumonia
• Pleural rub (movement of visceral over parietal pleura-
creaking sound)- pleurisy
• Vocal resonance- same findings as in vocal fremitus except
using a stethoscope to listen to the 999
Transmitted sounds
• Bronchophony- louder and clearer sounds heard when
patient asked to say repeatedly “ninety-nine”
• Whispering pectoriloquy- patient is asked to whisper 1, 2, 3.
There is increased quality and loudness of whispers that are
heard with a stethoscope over an area of lung consolidation
Some Physical Signs on Chest Examination
1. Lung Consolidation (eg pneumonia)
- Reduced chest expansion
- Dull percussion note
- Increased tactile vocal fremitus
- Increased vocal resonance
- Reduced air entry
- Bronchial sounds or Crepitations (crackles)
- Pleural rub may be present
2. Pleural effusion (fluid in pleural space)
• Trachea deviated to opposite side
• Reduce chest expansion
• Stony dull percussion note
• Decreased/absent breath sounds
• Reduced/absent vocal resonance/fremitus
3. Lung collapse and Fibrosis
• Trachea deviated to same side
• Reduced chest expansion
• Reduced percussion note (dull)
• Decrease breath sounds
• Bronchial breath sounds plus or minus crackles (in fibrosis)
4. Pneumothorax (air in pleural space)
• Trachea deviated to opposite side
• Decrease chest expansion
• Increase percussion note (hyper-resonant)
• Decrease breath sounds
5. Reduced chest expansion in the following conditions
• Consolidation (eg pneumonia)
• Effusion
• Collapse
• Pneumothorax
• Fibrosis
 Summary of Physical Signs in Respiratory Disease

Pathology Chest Trachea Percussion Breath Added

expansion deviation note sounds sounds
Asthma Reduced both nil normal Prolonged wheeze
sides expiration
Lobar Reduced on nil dull bronchial crackles
pneumonia affected side
Lung collapse Reduced on Towards dull diminished nil
affected side affected side
Localized Reduced on Towards dull bronchial crackles
fibrosis affected side affected side
Pneumothorax Reduced on To opposite Hyper- diminished nil
affected side side resonant
Pleural Reduced on To opposite Stony dull diminished Rarely
effusion affected side side pleural rub
 Diagnostic Tests for Respiratory Disorders
These tests:
• Check whether you take in air properly
• Assess whether your lungs are utilizing the oxygen you breathe
in
• Screen for anything disrupting lung function
• Check internal structures and tissues within the respiratory tract
1. Standard pulse oximeter
- A basic test to assess oxygen capacity. It is often a preliminary
assessment for both underlying heart and lung conditions
- The most commonly used pulse oximeter is attached to the tip
of the fingers. Others can be placed on the toes, nose, feet, ears
and forehead
- Within a few seconds it measures the pulse and oxygen
saturation in percentage. Ideal oxygen saturation is above 95%
2. Spirometry- evaluates your ability to breathe
- You take in a deep breath and breathe out through a tube as
quickly and completely as you can
- It is a simple preliminary test for underlying conditions which
limit breathing capacity through narrowing and inflammation of
bronchial tubes eg obstructive pulmonary disease (COPD)
3. Measuring Peak Flow Capacity
- It measures the airflow out of the lungs. After taking a deep
breath you will forcibly exhale through a plastic tube and repeat
at least 3 times
- Peak expiratory flow (PEF)- fastest flow rate recorded during
expiration. A result of over 80% is good
- Consistently decreased values should point to further
assessment for conditions such as asthma
4. Chest x-ray
- The most basic test if there is possible underlying lung disease.
It visualizes bigger opacities caused by infection such as
pneumonia or larger lung tumors
- Give information about the nature and location of
respiratory disease
Common chest x-ray findings
- Pneumonia- non-homogenous opacity of lobe/area involved
- TB- non- homogenous opacity below the clavicle or in the
first intercostal space and not beyond or apical opacity with
or without a cavity
- Lung abscess- non-homogenous opacity with fluid level seen
in area involved
- Pleural effusion- homogenous lower zone opacity with a
cresentric upper border
- Pneumothorax- hyper-translucent area, devoid of lung
markings in the pleural cavity
- COPD- hyper-translucent lung fields with exaggerated
vascular markings, a flattened diaphragm and a long
narrow heart
5. Computed Tomography (CT scan)
- Smaller changes in the lungs are often difficult to see with
chest x-ray. This is where a CT scan helps
- Due to detailed images provided a CT scan often helps to
conclude diagnoses for conditions like pneumonia,
tumors, pulmonary embolism
6. Bronchoscopy
- A small, thin, flexible tube with a camera is slowly passed
through the respiratory passages
- The camera helps to highlight tumors, sources of bleeding
or obstruction. Also help to collect biopsy samples for
further testing
7. Lung Biopsies
- During x-rays or CT scan, nodules or abnormal masses can
be noted
- To confirm a diagnosis in such cases and to rule out cancer,
a biopsy may be required
- Samples are collected and sent to a pathology lab for
further conclusive diagnosis
- It is a last resort diagnostic test when other tests are
inconclusive or malignancy needs to be ruled out
8. Body fluids testing
• Sputum
- Identify bacteria- gram stain, AFB (acid fast bacilli)
- Culture and drug sensitivity- takes 24-48 hours for bacteria
and 1-8 weeks for mycobacteria
• Blood tests
- Full blood count (FBC) and differentials
9. Skin Tests- skin-prick testing

• Multiple positive- asthma

• Tuberculin test- tuberculosis
 2. Cardiovascular System

Presenting symptoms
• Dyspnea- uncomfortable awareness of breathing
Determine level of dyspnea by type of activity/exertion
causing dyspnea
- Grade 1- dyspnea at supra-ordinary activities- shortness of
breath while running
- Grade 2- dyspnea at ordinary activities- shortness of breath
while farming, climbing uphill
- Grade 3- dyspnea at sub-ordinary activities- short of breath
while combing hair, going to toilet
- Grade 4- dyspnea at rest
Difference between dyspnea of CVS and RS
Cardiac Respiratory
- Cough after dyspnea cough proceeds dyspnea
- Orthopnea, PND no orthopnea, PND
- Edema no edema
- Raised JVP JVP not raised
- Change with diuretics no change with diuretics
- No sputum production sputum production
- Wheezing not common wheezing more common
• Orthopnea- dyspnea while assuming supine position due
to gravitational pooling of blood to the lungs
Causes- LVF (common), massive ascites, massive pleural
effusion, pregnancy
• Paroxysmal nocturnal dyspnea- sudden breathlessness at
night which wakes up patient from sleep choking or
gasping for air
• Palpitation- unpleasant awareness of the heart beat
• Ankle swelling- excess fluid from heart failure will settle
where gravity pulls it. Cardiac edema is worse towards the
evening. Anasarca is gross, generalized swelling
• Syncope (simple faint)- transient loss of consciousness
resulting from cerebral anoxia.
Causes- postural hypotension, arrhythmias
• Chest pain (angina)- retrosternal chest pain with
squeezing, heaviness, pressure or burning character,
radiating to the left shoulder, neck, jaw, teeth and medial
border of left arm, which is worsened by exertion and
relieved by rest or nitrates
Types- stable angina, unstable angina, angina in acute
Myocardial infarction
• Fatigue- common symptom of cardiac cause
• Intermittent claudication- pain in one or both calves,
thighs or buttocks when they walk more than a
certain distance. The distance walked inducing
claudication is claudication distance
• Cough- productive of frothy sputum flecked with
blood due to pulmonary edema
 Physical Examination

1. Peripheral
At end of bed
• Look for signs of breathlessness or distress
Hands
• Peripheral cyanosis
• Check capillary refill
- Apply 5 secs of pressure of the distal phalanx of one of
the patient’s fingers and then release
- Normal- the initial pallor of the compressed area
should return to its normal in <2 seconds
- >2seconds- suggests poor peripheral perfusion (CCF,
hypovolemia)
• Examine nails for clubbing
• Splinter hemorrhages (fine longitudinal bleeds under nails)-
infective endocarditis in a febrile patient
• Take blood pressure (BP)
- Use the right cuff for the right patient- we have child,
standard adult and large adult cuffs
- Patient should be relaxed
- Monitor the radial pulse and inflate the cuff until the radial
pulse is no more palpable
- Listen over the brachial artery with the diaphragm or
bell of the stethoscope
- Note the point at which the pulsation is audible
(korotkoff phase I)- record as systolic BP
- Note the point at which the sounds
disappear(korotkoff phase V)- record as diastolic BP
- Record the BP as systolic/diastolic
• Peripheral arterial pulses (radial, brachial, carotid,
femoral, popliteal, posterior tibial, dorsalis pedis)
- Rhythm (regular, regularly irregular, totally irregular)
- Pulse character- best assessed in the carotid
o Hypokinetic pulse- hypovolemia, LHF
o Hyperkinetic pulse- large, bounding pulse- anemia,
thyrotoxicosis, pregnancy
o Pulse bisferiens- waveform with 2 peaks
o Water hammer (collapsing) pulse- suddenly hits your fingers
and fall back- aortic regurgitation
o Pulsus alternans- alternating strong and weak pulse-
advanced heart failure
o Pulsus paradoxus- decrease in amplitude during inspiration-
pericardial tamponade, status asthmaticus
- Pulse volume
- Radio-femoral delay- pulses palpated together and delay in
pulsation reaching the femoral artery-coarctation of aorta
- Radio-radial delay- aneurysm at aortic arch, subclavian
artery stenosis
Pulses commonly palpable
- Radial artery- just medial to the radial styloid process
- Brachial artery- medial side of the antecubital fossa; medial to
the tendinous insertion of the biceps
- Carotid artery- from the larynx laterally backwards medial to the
sternomastoid
- Femoral artery- midway between the pubic tubercle and the
anterior superior iliac spine
- Popliteal artery- center of popliteal fossa; press with pressure
with tip of fingers
- Posterior tibial artery- posterior and inferior to the medial
malleolus
- Dorsalis pedis artery- superior surface of the foot between the
bases of the 1st and 2nd metatarsal bones
- Pulse rate
o Normal pulse- 60-100 beats/minute
o Bradycardia- < 60 beats/minute
o Tachycardia- > 100 beats/minute
Face and Neck
• Check and measure JVP (Jugular Venous Pressure)- with
patient lying back with neck exposed and head turn to left.
- Measure the vertical distance from the top of the pulsation
to the sternal angle (Angle of Loius)
- Then add 5cm (this is the distance from the center of the right
atrium to the sternal angle) to give the true JVP which is 8cm.
- If true JVP is above 8cm it is raised and is due to: Right
ventricular failure, fluid overload etc
Differentiating Carotid pulse from JVP
JVP Carotid pulsation
- 2 peaks in sinus rhythm 1 peak
- Impalpable palpable
- Obliterated by pressure hard to obliterate
- Moves with respiration little movement
- Hepatojugular reflex rise JVP will not
• Hepatojugular or abdominojugular reflux/test- exert
pressure over the liver with your right palm and the
JVP will rise> 4cm- constrictive pericarditis, RHF,
restrictive cardiomyopathy
• Check conjunctiva for pallor
• Look at lips and tongue for central cyanosis
• Check eyes for xanthelasma (harmless yellow bump
on or near eyelid)- can be a sign of heart disease
 Examination of the Precordium

The precordium is that part of the chest overlying the heart

Inspection
• Scars of cardiac operations- vertical scar on sternum
• Pacemaker – over left pectoral region
• Visible apical impulse (apex beat)
- Defined as the lowest and most lateral point at which the
cardiac impulse can be palpated (located at the left fifth
intercostal space midclavicular line)
- If displaced- left ventricular enlargement, chest wall
deformity (scoliosis, mediastinal shift)
Palpation
Place the flat of your right hand on the chest wall to the
left, then to the right
• Parasternal Heave- palpable impulse that lifts
examiner’s hand. Usually felt at the left sternal edge-
right ventricular enlargement
• Thrill- palpable (transmitted ) murmur felt beneath
the hand- If systolic- aortic stenosis, ventricular septal
defect, mitral regurgitation. If diastolic- mitral stenosis
• Apex beat
- Normal position- usually at the left 5th intercostal space,
midclavicular line
- Abnormal position (more lateral)- enlarged heart, disease of
the chest wall
- No apex beat felt means:
Obesity or excessively muscular chest wall
Pericardial effusion, emphysematous lung
Constrictive pericarditis, dextrocardia, death
- Stronger and more forceful- hyperdynamic circulation
(anemia, sepsis)
- Tapping- severe mitral stenosis
- Diffuse and poorly localized- left ventricular aneurysm
- Sustained and impulse longer than expected- left ventricular hypertrophy,
aortic stenosis, hypertrophic cardiomyopathy
- Double impulse- hypertrophic cardiomyopathy
• Percussion
This is to demarcate the heart margin which is not useful and therefore not
included in cardiovascular examination
• Auscultation-
There are 4 main (standard) auscultation areas
- Mitral(apex)- left 5th intercostal space mid-clavicular line
- Tricuspid- 4th intercostal space at the left sternal edge
- Pulmonary- 2nd intercostal space at the left sternal edge
- Aortic- 2nd intercostal space at the right sternal edge
To locate these standard areas you have to locate the 2 nd intercostal
space first
Landmarks to use
- Angle of Louis (joint of manubrium and sternum) is in line with the 2 nd
rib, and below it is the 2nd intercostal space
- Can also use sternal end of the clavicle as landmark- it lies over the 1 st
rib and below it is the 1st intercostal space
Auscultate at each of the 4 standard areas.
The bell of the stethoscope is used to detect low-pitched sounds (S3, S4)
and the diaphragm high-pitched sounds (S1, S2)
Listen with the diaphragm at each area and then repeat using the bell.
You can then go back and concentrate on any abnormalities detected
If you are not sure which is the 1st and 2nd heart sound,
palpate one carotid pulse whilst listening to the heart.
The carotid pulsation occurs with the first heart sound
Normal heart sounds
Should be tuned against the carotid pulse
First heart Sound (S1)
Heard as “lub”. Mitral valve closure is the main
component. The sound immediately before the carotid
pulsation. Loudest at the apex
Second heart Sound (S2)
Heard as- “dub”. This is due to closure of the aortic and
pulmonary valves. The sound follows the carotid pulsation.
Best heard at the upper left sternal edge using diaphragm of
stethoscope
The 2 heart sounds (S1, S2)are often described as “lub dub”
Splitting S2
During inspiration the pulmonary valve close very slightly
later than the aortic valve, producing a split 2nd sound (“lub
da-dub”)
Abnormal (added) heart sounds
1. Third heart Sound (S3)- Sound occurring just after S2.
Described as triple or gallop rhythm- “lub-da-dum”
- Physiological- normal in children and fit adults up to 40,
pregnancy. Heard only at apex
- Pathological- aortic regurgitation, mitral regurgitation,
constrictive pericarditis, anemia, thyrotoxicosis
2. Fourth heart Sound (S4)- sound occurring just before S1.
Described as “da-lub dub”
- Never physiological. Usually pathological
- Causes- hypertensive heart disease, hypertrophic
cardiomyopathy
3. Heart Murmurs
They are produced by turbulent blood flow through
faulty valves
If murmur is heard determine whether they are
systolic, diastolic or continuous in comparison to the
carotid pulse. Systolic murmur coincide with the carotid
pulse while diastolic murmur do not
Systolic Murmurs
• Ejection systolic murmur. Best heard at the apex and
right sternal edge- aortic stenosis
• Pansystolic murmur. Best heard at the apex. Radiates
to the axilla- murmur of mitral regurgitation
Diastolic Murmurs
• Best heard with patient rolled onto the left side and
using the bell to auscultate at the apex- mitral
stenosis
• Best heard with patient sitting, leaning forward and
breathing out. Heard at left sternal edge using the
diaphragm- aortic regurgitation
4. Pericardial rub- a scratching sound heard with each heart
beat caused by inflamed pericardial membranes rubbing
against each other in pericarditis
5. Carotid bruits- ask patient to hold their breath and
auscultate over the carotids
Other Cardiovascular Examination
The CVS examination is not complete without the examination
of:
• Lung bases- look for basal lung crackles- LHF
• Abdomen
- Hepatosplenomegaly, ascites- RHF, CCF
• Legs- peripheral edema- RHF, CCF
Ankle edema of cardiac origin is usually symmetrical and
worsens in the evening and improves early in the morning
Examination
Press gently on both legs above the medial malleoli with
both thumbs for a while and see/feel if a dent
Grades of Edema
- Grade 1- pedal and pretibial edema
- Grade 2- edema involving leg and thigh
- Grade 3- edema involving abdominal wall and pre-sacrum
- Grade 4- anasarca (generalized edema)
• Varicose veins
• Abdominal aortic aneurysm- bruits above umbilicus
• Renal artery stenosis- bruits left/right of umbilicus
 Investigations

1. Blood tests
• Full blood count (FBC)- presence of infection, anemia and
other blood disorders
• Electrolytes, urea and nitrogen- identify electrolyte imbalance
and define renal function. May contribute to cardiac
arrhythmias
• Liver function test- poor cardiac output may disrupt liver
function
• Cardiac troponins- diagnosis of myocardial infarction (MI)
• Thyroid function tests- thyroid dysfunction may cause cardiac
failure or precipitate atrial fibrillation
2. Electrocardiogram (ECG)- electrical activity of the heart. Identifies
heart rate, conduction disturbances, myocardial ischemia and
possible structural defects
3. Stress test (exercise tolerance test or thread mill test)- similar to
ECG but records the activity of the heart as it works harder
4. Chest x-ray- differentiates between respiratory and cardiac causes
of dyspnea. In heart failure common findings include:
cardiomegaly, interstitial edema, pulmonary edema, pleural
effusion
5. Echocardiography- provides ultrasound image of the cardiac
anatomy. Provides information about chamber size/shape, blood
flow velocities, systolic and diastolic functions, contractility, valve
function and presence of thrombus
6. Coronary angiography- identifies the presence,
location and narrowing of the coronary vessels
7. Magnetic resonance imaging (MRI)- provides
accurate information about cardiac volume, muscle
mass, contractility, tissue scarring, location and size
of myocardial infarction
8. Computerized tomography- identification of
aneurysms and valve dysfunction and pulmonary
vein anatomy
3. Gastrointestinal Tract (GIT)/Abdomen Examination

Presenting symptoms
• Dysphagia- difficulty in swallowing. Does food stick when
you swallow
- Difficulty in initiating swallowing with fluid regurgitation
into nose or choking- neurologic disorders
- Food sticking lower retrosternal area- lower esophageal
obstruction
- Swallowing difficulty more to liquids than solids- achalasia,
diffuse esophageal spasm
- Progressive early to solids, then to liquids- esophageal
stricture or cancer
• Odynophagia- pain during swallowing
- Causes- infective esophagitis (candida), caustic damage,
drug allergy (sulphonamides)
• Dyspepsia (indigestion)- sustained burning pain. Presents
as upper abdominal discomfort, bloating or belching
• Nausea and vomiting
- Nausea- involuntary effort to vomit
- Vomiting (emesis)- forceful expulsion of gastric contents by
reflex contraction
- Acute onset vomiting- food poisoning, bowel obstruction,
raised intracranial pressure
- Chronic onset vomiting- pregnancy, pyloric stenosis,
medications (digoxin, chemotherapy)
- Vomiting after 1 hour of meal- gastric outlet obstruction
- Early morning vomiting before eating- pregnancy,
increased intracranial pressure
- Vomiting blood- bleeding upper GIT
- Vomiting feculent material- intestinal obstruction
- Projectile vomiting of non-bilious old food, relieving
dyspepsia- gastric outlet obstruction (pyloric stenosis)
• Abdominal pain
Pain and their embryologic origin
- Foregut pain (localizes to the epigastrium)- originate from
stomach, pancreas, hepatobiliary structures
- Midgut pain (felt periumbilical)- originate from small bowel and
proximal large colon
- Hindgut pain (localizes to suprapubic area)- large bowel,
urogenital organs
The location of the abdominal pain can indicate the underlying
cause.
The anterior abdominal wall is artificially divided into 9 regions for
descriptive purposes and for differential diagnosis of pain.
Four imaginary lines can be drawn to give the 9 regions
- 1 horizontal line between the anterior superior iliac
spines
- 1 horizontal line between the lower border of the ribs
- 2 vertical lines at the mid-clavicular point
The organs lying in each area are enumerated below:
 Right upper quadrant (hypochondrium) pain-
cholecystitis, biliary colic, hepatitis , peptic ulcer, colon
cancer, subphrenic abscess, basal pneumonia,
congestive hepatomegaly
 Epigastric pain- gastritis, peptic ulcer, pancreatitis, aortic
aneurysm, myocardial infarction
 Left upper quadrant pain- peptic ulcer, colon cancer, ruptured
spleen, subphrenic abscess, basal pneumonia, splenic infarct
 Left iliac fossa pain- colon cancer, pelvic abscess, diverticulitis,
volvulus, UTI, cancer in undescended testis, renal colic, hip
pathology, constipation, in addition to female(salpingitis,
torsion of ovarian cyst)
 Loin pain (right and left)- renal colic, pyelonephritis, renal
tumor, perinephric abscess, referred pain from vertebral
column
 Right iliac fossa pain- all causes above including
diverticulitis plus appendicitis
 Central pain- mesenteric ischemia, abdominal
aneurysm, pancreatitis, worms, bowel obstruction ,
gastroenteritis
 Pelvic pain/supra-pubic pain- UTI, urine retention,
bladder stones, and addition in the female (menstrual,
early pregnancy with problems, endometriosis,
endometritis, salpingitis, torsion of ovarian cyst)
Establish the pain using SOCRATES.
• Abdominal distension
The six classical causes of generalized abdominal swelling (the 6Fs). The
first 5Fs cause symmetrical swelling, and the last F cause asymmetrical
swelling.
The clinical significance of the 6 F’s
- Fat- obesity
- Fluid (ascites)- cirrhosis of liver, CCF, chronic renal failure
- Flatus- bowel obstruction, paralytic ileus
- Feces- chronic constipation, chronic intestinal obstruction
- Fetus- pregnancy
- Fulminant/flipping masses- uterine fibroids, giant
hepatomegaly/splenomegaly, polycystic kidneys, abdominal cysts
(renal, pancreatic, ovarian), full bladder (urine retention)
• Diarrhea- passage of watery loose stools > 3 times per day
or passage of large amount of stool >300gm per day
- Acute diarrhea- < 2 weeks. Caused by infections
- Persistent diarrhea- 2-4 weeks
- Chronic diarrhea- > 4 weeks. Non-infectious causes
• Constipation
- Normal frequency of bowel movements- 3 times daily to
once every 3 days
- Constipation is persistent, difficult, infrequent and
seemingly incomplete defecation. Passage of formed stools
< 3 times per week
- Recent onset- colonic obstruction (cancer, colon stricture), anal
sphincter spasm (anal fissure, painful hemorrhoids)
- Chronic onset- inflammatory bowel disease, medications
(codeine, calcium antacids), endocrine (hypothyroidism,
hypercalcemia)
• Hematemesis- vomiting of frank blood- PUD, gastric cancer,
esophageal varices
• Malena- tarry, foul smelling stool- bleeding above ileo-cecal
valve, iron tablets
• Hematochezia- rectal bleeding- bleeding from sigmoid colon-
rectum or anal canal. Common causes- hemorrhoids, anal
fissure, colorectal polyp/cancer
• Jaundice (icterus) – yellow pigmentation of the skin,
sclera and mucosa caused by excess bilirubin in the
body fluids
• Pruritus- itching of the skin (localized or generalized).
It is particularly associated with cholestatic liver
disease
Physical Examination
• Peripheral examination
End of bed
- Look for signs of pain. Does it make him lie still (peritonitis)
or writhe about (colic)
- Weight loss
Hands
- Palmar erythema (reddish base of palms)- cirrhosis of liver,
pregnancy, polycythemia
- Dupuytren’s contracture (fibrosis and contracture of palmar
fascia)- liver disease, epilepsy, trauma, ageing
- Examine for asterixis- liver disease
Body Mass Index
The body mass index (BMI) is a useful estimate for body
fatness
BMI = Weight (kg)/[height (m)] square
The BMI is classified as follows:
- 19-25 = normal
- 25-30 = overweight
- 30-40 = obese
- > 40 = extreme or morbid obesity
Face
- Xanthelasma- chronic cholestasis
- Parotid swelling- alcoholic abuse
- Signs of dehydration- sunken eyes, dry mucous membranes
Examination of the Abdomen
Expose the chest (nipple line) up to mid thigh (may leave bra
on and cover genital area)
Inspection
• Look for symmetry of abdomen and flank fullness by
standing at the bed end.
• Look at shape of abdomen- scaphoid, flat, distended.
Think of the 6Fs
• Look at the contour of the umbilicus- inverted is normal
• Look for abdominal movement with respiration. Silent
abdomen- generalized peritonitis
• Scars- site of scar would suggest the previous operation
done
• Prominent veins- portal HPT, obstruction vena cava
• Caput medusa (veins flowing away from umbilicus)-
hepatic cirrhosis
• Look for visible peristalsis- bowel obstruction
• Prominent superficial veins- Caput medusae
• Striae- ascites, Cushing’s syndrome, pregnancy
• Look at hernia sites- demonstrate cough impulse. Ask patient to
cough and look for a bulge
• Pulsations (pulsatile expanding mass)
- Aneurysm of abdominal aorta
• Cullen’s sign- bruising of the tissue around the umbilicus-
associated with hemorrhagic pancreatitis (late sign),
retroperitoneal/intraabdominal hemorrhage
• Grey-turner’s sign- bruising in the flanks- associated with
hemorrhagic pancreatitis (late sign)
Palpation
Kneel or sit on patient right hand side. Ask if they have pain
1. Light/superficial palpation
Whilst palpating be looking at the face for any reaction
Start away
from the site of pain and end there last. Lightly palpate each
of the 9 regions of the abdomen
• For tenderness
• For rebound tenderness (Blumberg’s sign)- compress the
abdominal wall slowly and release rapidly. This results in
sudden sharp abdominal pain- associated with peritonitis
• For involuntary guarding/rigidity- involuntary reflex
contraction of abdominal wall muscles underlying an
inflamed viscus- associated with peritonitis
• McBurney’s sign- the presence of severe pain when
pressure is quickly released after applying slow
pressure over the McBurney’s point (located at 1/3 of
distance from anterior superior iliac spine to the
umbilicus). Positive McBurney’s sign implies possible
appendicitis, inflammation of ileocolic area (Crohn
disease or bacterial infection). The following
maneuvers can help identify appendicitis:
- Rovsing’s sign- palpation of the left iliac fossa causes
pain to be experienced in the right iliac fossa- historically
said to be indicative of acute appendicitis
- Psoas sign- place hand above patient right knee and ask
him to push up against your hand. This contraction of
psoas muscle causes pain
- Obturator sign- flex patient right thigh at the hip with
knee flexed and rotate internally. Increased pain in the
lower quadrant suggests appendicitis. This is due to
inflammation of obturator muscle from overlying
appendicitis or abscess
• Large/superficial masses may also be noted on light
palpation
Signs of Peritonitis
- Abdomen does not move with respiration
- Tenderness (Pain) on light palpation
- Rebound tenderness
- Involuntary guarding
- Absent bowel sounds
2. Deep Palpation
Palpate each of the 9 regions of the abdomen, this time applying
greater pressure.
- To delineate abdominal mass
- To confirm presence of organomegaly (liver, spleen, kidneys)
If any mass is identified, assess the following characteristics:
- Location- which of the 9 regions is it located
- Size and shape- approximate its size and shape
- Consistency- smooth, soft, hard, irregular
- Mobility- attached to superficial or underlying structures
- Pulsatility- does the mass pulsate, suggestive of vascular etiology
• Palpate the liver (normally not palpable)
- Begin in the right iliac fossa, starting at the edge of the anterior
superior iliac spine using the flat edge of your hand (radial edge
of the right index finger)
- Ask patient to take a deep breath. As they begin to do that
palpate the abdomen
- Repeat the process of palpation moving 1-2cm (1 finger breath)
superiorly from the right iliac fossa towards the right costal
margin
- If you are able to identify the liver edge, measure the extension
below the costal margin (in cm or finger breaths below costal
margin)
• Palpate the Gall bladder (normally not palpable)
- Position your fingers at the right costal margin in the
midclavicular line at the edge of the liver
- Ask patient to take a deep breath
- If patient suddenly stops mid-breath due to pain, this
suggests the presence of cholecystitis (Murphy’s sign
is positive)
- A distended, painless gall bladder, associated with
jaundice may indicate underlying pancreatic cancer
Palpate the Spleen
- Begin palpation in the right iliac fossa as in the palpation of the
liver
- Palpate the abdomen with your fingers aligned with the left
costal margin
- Feel for a step (splenic notch) as the splenic edge passes below
your hand
- Repeat this process of palpation moving 1-2cm (1finger breath)
superiorly from the right iliac fossa towards the left costal margin
- Measure the distance to the costal border in finger breadths or
cm
- In healthy individuals it is not palpable
• Ballot the kidneys- not ballotable in healthy individuals
- Place your left hand behind the patient’s back, below the ribs
and underneath the right flank
- Then place your right hand on the anterior abdominal wall just
below the right costal margin in the right flank
- Push your fingers together, pressing upwards with your left
hand and downwards with your right hand
- Ask patient to take a deep breath, feel for the lower pole of the
kidney moving down between the fingers. This process is
called bimanual palpation and is known as balloting
- Repeat the process on the opposite side to ballot the left
kidney
Differentiating an enlarged spleen and an enlarged left
kidney (both are located in the LUQ)
Enlarged spleen Enlarged left kidney
- Impossible to feel above it -Possible to feel above it
- Has a central notch medially-No notch
- Dullness to percussion - Resonant percussion note
- Not ballotable - Ballotable
- Enlarge towards umbilicus - Enlarges inferiorly
- Moves inferio-medially on - Moves inferiorly on
inspiration inspiration
• Palpate the Aorta
- Using both hands perform deep palpation just superior to the
umbilicus in the midline
- In healthy individuals, your hands will move superioly with each
pulsation
- If your hands move outwards, it suggests the presence of an
expansile mass (abdominal aortic aneurysm)
• Palpate the bladder
- Only a distended bladder can be palpated in the suprapubic
area arising from behind the pubic symphysis
- In healthy patients who are passing urine regularly the bladder
will not be palpable
• Palpate abdominal mass
- Location (abdominal wall or intra-abdominal)- feel the swelling
while patient lifts up head with shoulders. Prominent ,
protruding swelling indicates abdominal wall mass, if swelling
disappears it is an intra-abdominal mass
- Shape- nodular, hard, irregular outline (malignancy), solid,
tender, ill-defined (inflammatory), regular, round, smooth and
tense (cyst)
- Mobility- moves down with respiration (arising from liver,
spleen, gall bladder and stomach), no movement with
respiration (arise from bowel, omentum), moves side-to-side in
lower abdomen (gravid uterus, uterine myoma)
- Attachment- fixed swelling (retroperitoneal origin)
Percussion
Normal abdomen is tympanitic in percussion note
• Percuss the liver
- Percuss upwards 1-2cm at a time from the right iliac fossa
towards the right costal margin until the percussion note
changes from resonant to dull indicating the location of the
lower liver border
- Continue to percuss until the percussion note changes from dull
to resonant indicating the location of the upper liver border
- Determine the approximate size between the two borders
• Percuss the Spleen
- Percuss upwards 1-2cm at a time from the right iliac fossa
towards the left costal margin until the percussion note changes
from resonant to dull indicating the location of the spleen
- In the absence of splenomegaly do not identify the spleen using
percussion
• Percuss the Bladder
- Percuss downwards in the midline from the umbilical region
towards the pubic symphysis
- A distended bladder will be dull to percussion allowing you to
approximate the bladder’s upper border
• Detection of Ascites
Shifting dullness
- Percuss from the umbilical region to the patient’s left flank. If
dullness is noted, this may suggest presence of fluid in the flank
- Whilst keeping your fingers over the area at which the
percussion note became dull, ask the patient to turn onto their
right side (towards you)
- Keep patient on the right side for 30secs and then repeat
percussion over the same area
- If fluid is present, the area that was previously dull should now
be resonant (ie the dullness has shifted)
Fluid thrill
- Need an assistant to place hand in the middle of the abdomen
longitudinally (to block transmission waves through the
abdominal wall to the opposite side)
- Flick on one side of the abdomen with 1 finger of one hand and
the palm of the other hand on the other side of the abdomen to
receive the impulse
Abdominal Auscultation
For detection of bowel sounds and vascular bruits
Bowel sounds
- Auscultate at least 2 positions on the abdomen below umbilicus
- Press the diaphragm of the stethoscope deep, for 2
minutes to be able to confidently state that the
patient has absent bowel sounds
- Increased frequency- diarrhea, mechanical bowel
obstruction
- Decreased/absent bowel sounds- paralytic ileus,
generalized peritonitis
Vascular bruits
- Aortic bruits- auscultate 1-2cm superior to the
umbilicus- abdominal aortic aneurysm
- Renal bruits- auscultate 1-2cm superior to the
umbilicus and slightly lateral to the midline on each
side (renal artery stenosis)
- Bruits over abdominal mass- malignancy, aneurysm
Succussion splash
- Place diaphragm of stethoscope over epigastrium
- Roll patient briskly from side-to-side
- Splashing sound is heard if stomach is distended with
fluid (positive succession splash)- gastric outlet
obstruction, paralytic ileus
Digital Rectal Examination (DRE)
• Ask patient to lie on left lateral position with legs
bent and knees drawn up
• With pairs of gloves separate the buttocks and
inspect the perianal area for skin tags, warts, fistula,
abscess
• Ask patient to strain and watch for hemorrhoids,
rectal prolapse
• Lubricate the tip of your right index finger with jelly
• Place the pulp of your finger against the anus and
press firmly to allow the sphincters to relax then
gently advance the finger into the anal canal
• If patient experiences severe pain- anal fissure, anal
ulcer, ischio-rectal abscess, thrombose hemorrhoids
or prostatitis
• Assess the sphincter tone
• Rotate the finger around to feel for any thickening
and irregularities and points of tenderness
• In the male identify the prostate
- Normal is smooth, firm and rubbery
- Benign prostatic hyperplasia (BPH) is enlarged, central
sulcus preserved, often exaggerated
- Prostate cancer is hard with irregular and nodular
lateral lobes and often distortion of the central sulcus
• Gently withdraw your finger and inspect the glove for
blood, mucus, color of stool
• It is conventional to record the position of a mass felt on
a clock face with 12 o’clock indicating anterior rectum
Examination of Groin
In a supine position ask patient to give a loud cough
and feel with hand for any impulse at the groin. Positive
cough impulse suggests inguinal hernia. It is better
when the patient stands
Differentiating Hernia Types
• Inguinal hernia- are typically located above and
medial to the pubic tubercle
• Femoral hernia- are typically located below and lateral to the
pubic tubercle
• Reducible hernia- is one which can be flattened out with
changes in position (lying supine) or the application of pressure
- Ask patient to lie supine and observe for evidence of
spontaneous reduction
- If the hernia is still present try to manually reduce it using your
fingers
- The hernia may reappear if the patient stands up, coughs or
application of pressure is removed
- Tender irreducible hernia may be strangulated
• Direct and Indirect Hernia
- Locate the deep inguinal ring (midway between the anterior
superior iliac spine and the pubic tubercle)
- Manually reduce the patient’s hernia
- Once the hernia is reduced, apply pressure over the deep
inguinal ring (as located above) and ask the patient to cough
- If hernia reappears it is more likely to be a direct inguinal hernia
- If hernia does not reappear it is more likely to be an indirect
inguinal hernia
Other abdominal Hernias- umbilical, epigastrium, incisional,
interstitial hernia(sac located within layers of abdominal wall)
Differentials of inguinal hernia
- Femoral hernia
- Hydrocele (able to get above swelling)
- Epididymal cyst
- Undescended/ectopic testis (empty scrotum)
- Inguinal lymphadenopathy
Differentials of femoral hernia
- Aneurysm of femoral artery
- Saphenovarix
- Psoas abscess
- Inguinal lymphadenopathy
Diagnostic Tests
1. Laboratory tests
• Fecal occult blood (means it can’t be seen with naked eye)- used
to determine bleeding in GIT- cancers, polyps
• Stool routine examination- for parasites, ova, bacteria, fat content
• Stool cultures- for abnormal bacteria in the gut
• Breath tests- help diagnose H. pylori, bacterial overgrowth
• Blood
- Total bilirubin and alkaline phosphatase- evaluate biliary system
- Amylase, lipase and calcium- evaluate pancreas function
• Urine - Bilirubin, urobilinogen and amylase- evaluate GI function
2. Endoscopy- direct vision and biopsy of lesions as well as
therapeutic interventions
• Upper gastrointestinal endoscopy- esophagitis, gastric ulcers
and tumors, duodenal ulcers are readily seen and biopsied
and bleeding can be arrested
• Sigmoidoscopy and colonoscopy- used to examine distal and
entire colon
• Laparoscopy – direct vision of the abdominal cavity for intra-
abdominal disease through a small incision in the abdominal
wall
3. Imaging
• Barium meal/enema (endoscopy has reduced the need)- it helps
detect ulcers, hiatal hernia, tumors or inflammation and colon
polyps, tumors and chronic inflammatory bowel disease
• Plain abdominal x-ray- to confirm clinical suspicions of intestinal
obstruction, stones
• Ultrasonography (USG)- assist in diagnosing cysts, tumors and
stones
• Computed tomography (CT)- assess patients with gallbladder,
biliary system or pancreatic problems
• Magnetic resonance imaging (MRI)- generate detailed images of
organs, soft tissues, bone and all other structures within the body
4. Biopsy- for confirmation and staging of tumor
 4. Integumentary System(Skin, Hair and Nails)

Introduction
• Skin- acts as physical, biochemical and immunological barrier
between the outside world and the body. It is made of 3 layers:
epidermis, dermis and subcutaneous
- Epidermis- the outermost layer
- Dermis- below the epidermis and contain the muscles, nerves and
blood vessels
- Subcutaneous (hypodermis) layer- consists of adipose tissue.
• Hair- formed by follicles of specialized epidermal cells buried deep
into the dermis
• Nails- sheets of keratin continuously produced at the proximal
end of the nail plate. They grow at 0.1mm/day
 Presenting Symptoms

• Hair loss (alopecia)

• Abnormal Hair Growth
• Nail disorders
• Skin color/pigmentation
• Skin lesions/eruptions
• Lump
• Ulcer
Physical Examination
1. Color and Pigmentation
• Pallor- abnormal whitening of skin and buccal mucosa
• Jaundice- yellow pigmented skin
• Erythematous lesions- redness of skin caused by increased
blood supply to the area. They blanch when pressure is
applied
• Purpuric lesions-reddish/purple color of skin caused by
small blood vessels bleeding into the skin. They do not
blanch when pressure is applied
- Petechiae- small purpuric lesions < 2mm in diameter
- Ecchymoses- larger purpuric lesions > 2mm in
diameter and commonly referred to as a bruise
• Hypopigmented lesions- areas of paler skin- pityriasis
versicolor
• Depigmentation- areas of skin completely white-
vitiligo. General absence of skin pigment- albinism
• Hyperpigmented lesions- areas of darker skin
- Diffuse- Addison’s disease
- Discrete- linea nigra in pregnancy
2. Skin lesions and Eruptions (rash)
a. Morphology of skin lesions
• Primary skin lesions- develop as a direct result of a disease
process
- Macule- flat area of altered color<0.5cm diameter
- Patch- flat area of altered color > 0.5cm diameter
- Plaque- palpable flat lesion>1cm diameter
- Papule- solid raised palpable lesion<0.5cm diameter
- Nodule- solid raised palpable lesion>0.5cm diameter
- Vesicle- raised clear fluid-filled lesion<0.5cm diameter
- Blister- raised clear fluid-filled lesion>0.5cm diameter
- Bulla- raised clear fluid-filled lesion>10cm diameter
- Pustule- pus containing lesion<0.5cm diameter
- Abscess- localized accumulation of pus
- Wheal- transient, smooth, slightly raised lesion,
characteristically with pale center and a pink margin
- Boil/furuncle- staphylococcal infection around/within a hair
follicle
- Carbuncle- staphylococcal infection of adjacent hair
follicles (multiple boils/furuncles)
- Callus- hyperplastic epidermis- found on soles, palms and
areas of excessive friction
• Secondary skin lesions (are modifications of primary lesions that
occur due to trauma to, or evolution of, the primary lesion)
- Excoriation- loss of epidermis associated with trauma
- Lichenification- thickening of the epidermis with exaggeration of
normal skin lines caused by rubbing or scratching of area- eczema
- Scales- visible fragments of stratum corneum as it is shed from
the skin resembling fish skin- psoriasis
- Crust (scab)- a rough surface consisting of dried serum, blood,
bacteria and cellular debris
- Scar- new fibrous tissue which occurs after injury.
o Atrophic scar- thinning of normal tissues underlying the scar
resulting in a crater effect.
o Hypertrophic scar- involves hyper-proliferation of scar tissue
within the wound boundary resulting in a prominent scar
o Keloid- hyper-proliferation of scar tissue beyond wound
boundary resulting in scar that is significantly larger than the
original skin insult
- Fissure- sharply-defined linear or wedge-shaped tear in the
epidermis with abrupt walls
- Striae (stretch marks)- purple lines on the skin due to tearing
during rapid growth or overstretching of the skin- ascites,
Cushing’s syndrome, growth spurts, obesity, pregnancy,
intra-abdominal malignancy.
- Ulcer- localized defect in the skin of irregular size and shape
where epidermis and some dermis have been lost. Use the
pneumonic BBEDDS for inspection of an ulcer. Characteristics:
• Basics- site, size, shape (margin-regular, irregular)
• Base- healthy, granulation tissue, slough, bone, tendon
• Edge- PURSE
- Punched out- trophic, arterial ulcer
- Undermined- pressure, tuberculosis
- Rolled- basal cell carcinoma
- Sloping- venous
- Everted- squamous cell carcinoma
• Depth- the layer of skin it extends to (measure height)
• Discharge- pus, blood, serous fluid
• Surroundings- skin changes, color, scars
b. Distribution of Skin Lesions
• Symmetrical (generalized)- has an internal cause
• Asymmetrical (localized)- has an external cause
• Centripetal- concentration on trunk
• Centrifugal- concentration on face and distal extremities
• Flexor- eczema
• Extensor- psoriasis
c. Configuration (arrangement) of each skin Lesion
• Discoid (round/coined shaped)- discoid eczema,
lupus
• Annular (ring-like)- tinea corporis
• Circinate- circular
• Gyrate/serpiginous- wave-like
• Linear (in a line)- excoriations
• Clustered grouped
• Reticulate- net-like
3. Examination of a Lump
Use 6 Students and 3 Teachers go for CAMPFIRE as a guide
• Site- anatomical location
- Intradermal (lump in skin)- lump moves with the skin-
granuloma, sebaceous cyst, dermoid cyst
- Subcutaneous- skin moves over the lump- lipoma, ganglion,
lymph node, neuroma
• Size- can be estimated, but ideally should be measured and
stated in at least 2 or 3 dimensions eg I palpated a 3 by 5 by 5cm
mass
• Shape- description should be made in geometrical terms-
spherical, oval, round mass, etc
• Surface
- Smooth- cyst
- Lobular with smooth lumps- lipoma
- Nodular- matted lymph nodes
- Irregular/rough- carcinoma
• Skin- redness, ulcerated, pigmentation, discharge,
punctum, scars, sinus
• Surrounding area
- Pressure effects- edema, wasting
- Deformity
• Temperature (felt with dorsum of hand)
- Normal or warm (infection or well vascularized tumor)
• Tenderness- painful to touch- infection, malignancy
• Transillumination- shine a pen torch light across the lump
in a dark room. A swelling containing clear fluid will glow-
simple cyst, hydrocele, cystic hygroma and also a lipoma
• Consistency
- Hard- possibly cancer
- Firm (rubbery or spongy)- fluid-filled lumps
- Soft- likely benign- lipoma
• Attachment
- Does it move with muscle contraction? Then attached to muscle
or tendon
- Does it move only in one direction? Then attached to tendon or
nerve. If attached to nerve then patient might feel pins-and-
needles if compressed
• Mobility
- Movement with respiration- lumps from upper abdominal
viscera
- Movement with swallowing- lumps attached to larynx or trachea
- Movement with protrusion of tongue- thyroglossal cyst
• Pulsation- suggesting vascular origin
Place 2 fingers on either side of the lump
- Originating from lump itself- the fingers will move
upwards and outwards (expansile)
- Transmitted from nearby vessel- the fingers will move
upwards but not outwards
• Fluctuation- place your fingers on either side of the
lump, opposite each other. Press with one finger to the
center of the mass and feel whether the lump bounces
against your other fingers- fluid or fat-filled lump
• Irreducibility
- Compressibility- lumps that can be emptied by pressure but
reappear spontaneously on release of pressure- varicose veins,
saphena varix
- Reducibility- lumps which disappear with pressure and do not
return spontaneously- hernia
• Regional lymph nodes- lymph nodes which drain the site of the
lump
- Unusually firm/hard- malignancy
- Painful and tender- infection
- Fixed to surrounding tissues- malignancy
- Matted together- tuberculosis
• Edge
- Well defined- neoplastic and chronic inflammatory swellings
- Ill defined- acute inflammatory swellings
4. Hair and Scalp
• Hair loss(alopecia)
- Alopecia areata- sharply defined , non-inflammatory bald
patches on the scalp.
- Alopecia totalis- loss of hair from all of the scalp
- Alopecia universalis- loss of all body hair
- Scarring alopecia- inflammatory lesions causing hair loss
• Abnormal Hair Growth
- Hirsutism- is stiff or dark body hair, appearing on the
body where women do not commonly have hair- the
face, chest, lower abdomen, inner thighs and back-
caused by high androgen levels
- Hypertrichosis- excessive hair growth anywhere on
the body in either males or females- cause is
unknown
5. Hands and Nails
• Nail Disorders
- Splinter hemorrhages- tiny longitudinal streak hemorrhages
under nails- micro-emboli, trauma
- Pitting- punctate depressions of nail plate- eczema, psoriasis
- Onycholysis- separation of distal end of the nail plate from
the nail bed- psoriasis, fungal nail infection
- Leukonychia- white coloration of the nail caused by low
albumin or chronic ill health
- Beau’s lines- transverse depressions in the nail- sign of
arrested nail growth in acute illness
- Paronychia- infection of skin adjacent to nail
- Koilonychia- spooned shaped nail(concave indentation)-
iron deficiency anemia
- Clubbing- increased curvature of nail
- Onychomycosis- thickened, opaque and yellow nail- fungal
infection
6. EXAMINATION OF PIGMENTED LESIONS
ABCDE Assessment
- Asymmetry- refers to networks, patterns, markings, colors
or features that are not regularly distributed through the
entire lesion- is suggestive of malignancy
- Border- benign lesions typically have smooth and regular border.
If irregular border is present this increases the likelihood of
malignancy
- Color- benign lesions demonstrate uniform color throughout.
Presence of more than 2 colors increases the likelihood of
malignancy. Colors within pigmented lesions such as pink, blue,
grey, white or deep black increase likelihood of malignancy
- Diameter-progressively enlarging skin lesions, particularly those
with diameter of 6mm or more increases the likelihood of
malignancy
- Evolution- lesions growing quickly and/or changing in appearance
over a short period of time have concern for malignancy
Percussion
- Resonant- gas-filled lumps
- Dull- fluid-filled lumps
Auscultation

- Bruits- vascular lesions, enlarged thyroid

- Bowel sounds- over an inguinal hernia
 Investigations

1. Allergy testing
• Patch testing- very low concentrations of relevant allergens are
applied under patches on the back. The skin is then checked for
any reaction 2-4 days later

• Prick test- allergens are applied to the skin. The skin is pricked so
that the allergen goes under the skin surface
• Intradermal tests- a small amount of diluted allergen is injected
into the skin with a small needle
2. Skin biopsy- size and depth of biopsy depend on the nature of
the lesion- used to diagnose skin cancer or skin disorders
3. Skin culture- skin scrapings, hair or nails clippings may be
cultured to figure out which bacteria, fungi or viruses may be
causing the problem
4. Wood light (black light)- can help diagnose and define the
extent of lesions, distinguish hypopigmentation from
depigmentation

5. Swab from exudate, pus, blister aspirate for microscopy or

culture & sensitivity
6. Skin scrapings, nail clippings for examination under direct
microscopy- scabies, fungal infection
7. Blood samples for culture
 Example of History Taking and Physical Examination

• Identification of patient- Kofi, 30 years old, single and a

subsistent farmer living in a farm hut near a valley at
Kojokrom
• Present illness (PI)- cough and chest pain of 3 days duration
• History of present illness (HPI) (we would apply SOCRATES for
the cough and chest pain)
Kofi was apparently well until 3
days ago he developed a sudden cough (O) productive of
rusty sputum. The cough was throughout both day and night
(S) with no exacerbation or relieving factors (E). The cough
was getting worse (T) so he decided to visit the hospital. NB:
(Radiation), (Site) is not applicable to cough
The cough was associated with pain (A) which started the same day (O)
on the right side of the chest (Site) and stabbing © in character with a
severity score of 7/10 (S). Pain made worse by coughing and relieved at
rest (E). No radiation (R) of the pain and no associated factors (A)
• Review of systems- (Note that cough and chest pain are symptoms of
respiratory and cardiovascular, so ask questions on both)
- Cough productive of rusty sputum, short of breath, no wheezing and
no hemoptysis
- No orthopnea, no shortness of breath on exertion, no paroxysmal
nocturnal dyspnea or ankle edema, no claudication
- There was fever.
- All other systems were of no significance.
• PI- nil of significance
• Drug& allergy Hx- taken paracetamol since the onset of
the illness 1gm tid and mist expect sed 1 tablespoon tid
since onset of illness. He has also taken
athemeter/lumefantrine (80/480) 1 twice a day for 3 days.
Never had any allergy to any medication/herbs in the past
• Personal and Social Hx- he is a subsistent farmer, single,
takes the local gin ½ a bottle every evening before meals
for the past 5 years. Stays in a farm hut near a valley and
sleeps on a floor mat
• FHx- nil of significance
• Psychological assessment- well oriented in place , person and
time
• Summary (all positive and only important negative findings)
In summary, I present to you Kofi , a 30 year old subsistent
farmer with present illness of cough, chest pain of 3 days
duration.
Kofi was apparently well until 3 days ago he developed a sudden
onset of cough productive of rusty sputum associated with right
chest pain , stabbing in character and worse by coughing with
pain severity of 7/10.
Kofi was short of breath and not wheezing and no hemoptysis
with negative CVS symptoms (these are important negative
Kofi had headaches and fever.
He had taken paracetamol and anti- malarial with no effect and
no known drug/herbal allergy.
He is a chronic alcoholic and
his living condition exposes him to cold situations (sleeps near
valley on floor mat)
A provisional diagnosis of right pneumonia was made with a
differential diagnosis of asthma, COPD, pulmonary fibrosis, lung
cancer.
Suggested investigations: chest x-ray, Full Blood Count
Patient Ideas, Concerns and Expectations were addressed
On Examination:
• Vital signs- T= 38.5, P = 95, RR = 24, BP= 110/70 and weight = 60kg
• All the other systems (HEENT, lymphoglandular, CVS, the
abdomen, GUS,MSK,NS, Integumentary and Endocrine) were of
no significance
• The positive findings were in the respiratory system.
- On inspection kofi was having difficulty in breathing, using the
accessory muscles of respiration and reduced chest wall
movement on the right.
- On palpation trachea was central and chest expansion was
reduced on the right side with increased tactile vocal fremitus on
the right lower chest
• On percussion there was dullness on the right lower chest
• On auscultation bronchial breath sounds were heard over
the right lower lung with increased vocal resonance
The above physical examination findings conform with signs of
consolidation in the right lower lung, suggestive of pneumonia
on the right.
A plain chest x-ray shows a non-homogenous opacity of the
right lower lobe of the lung
I conclude that Kofi has a right lower lobe pneumonia

FINAL DIAGNOSIS: RIGHT LOBAR PNEUMONIA

Techniques of Physical Examination
(Skills lab- Demonstration of Skills)

1. GENERAL EXAMINATION
Position of Self
- Stand at the foot end of the bed on the right side of the
patient initiaally
Position and exposure of Patient
- Patient lying supine with head raised with pillow and chest,
abdomen and feet exposed whilst covering the genital area.
General
• Orientation in place, person and time- ask the following
questions:
- Where are you now?(place)
- Whom am I? (person)
- What part of the day are we now? (time).
• State how sick patient is
- Acutely or chronically ill looking?
- If ill looking- lying still (peritonitis) or writhing in pain
(colic)
• Pattern of breathing- Cheyne-stokes, Kussmaulor
normal breathing
• Shape/build- obese, cachectic or normal for the age
• Feet
- Check for varicose veins- present or absent
- Palpate for pitting edema- present or absent
Move up a bit and hold the patient’s hand
• Back of Hand
- Check hydration status- pinch skin of back of hand allow to go.
Does it go back slowly, very slowly or immediately?
• Palm
- Check for palmar pallor- is there no, some or severe palmar pallor
- Check palmar erythema
- Check Depuytren’s contracture
• Fingers
- Check for peripheral cyanosis- bluish finger tips
- Check for choilonychia, leukonychia, onycholysis
- Check for clubbing of fingers- Lovibond angle or
Schammroth’s sign
- Check for splinter hemorrhages, Beau’s lines, pitting
- Check for Herbeden’s nodes (DIP), Bouchard’s nodes
(PIP)
- Check for Swan neck and Boutonniere deformities
 Move to the head
• Sclera/conjunctiva
- Check for jaundice
- Check for pallor
• Let patient open Mouth and protrude the tongue
- Check for halitosis
- Check for central cyanosis
- Check for pallor
- Check for dehydration
Palpate for Enlarged lymph nodes
• Neck, axilla, epitrochlear, groin and popliteal regions
 2. Physical Examination of Respiratory System

Expose whole chest up to umbilicus with patient sitting

Inspection
• Look for respiratory distress
- Flaring alae nasi
- Tracheal tug
- Subcostal or intercostal recession
- Use of accessory muscles of respiration
• Count respiratory rate- if not already done as part of
vitals
• Observe breathing pattern- Cheyne-stokes, Kussmaul
• Observe chest wall movements- equal or not on both
sides
• Look for chest wall deformities- pectus carinatus,
excavatus, barrel chest, kyphosis, scoliosis, lordosis
• Examine sputum if available
Palpation
• Check fingers for clubbing, peripheral cyanosis, tar
staining- if not already done
• Check for cervical nodes – standing behind the patient
• Check trachea deviation- standing in-front of patient
Then let patient lie down
• Check tracheal tug
• Measure chest expansion
• Check tactile vocal fremitus
Percussion
Comparing both sides of the chest
• Percuss directly over clavicle
• Percuss anterior chest wall- at least 3-4 areas on each side
• Percuss lateral chest walls
• Percuss posterior chest wall- at least 3-4 areas on each side
- For dullness, stony dullness, hyper-resonance
Auscultation
Comparing both sides of the chest
• For vocal resonance
• For breath sounds (supraclavicular fossa, anterior, lateral,
posterior chest)- are they diminished, absent or bronchial?
• For added sounds- are there rhonchi, crepitations or
crackles, pleural rub, whispering pectoriloquy?
 3. Physical Examination of the Cardiovascular System

Expose whole chest up to the umbilical level with patient

lying at 45 degrees elevation
Inspection
• Is patient short of breath at rest?
• Is there any cyanosis? (peripheral, central)
• Look for the JVP with head turned to the left. Is it
elevated?
• Look at the precordium (part of chest overlying the heart)
- Any scars of heart operations or pace-maker inserted?
- An abnormal chest shape or movements
• Any visible pulsations?
• Look for ascites
• Any pedal edema?
• Any varicose veins?
Palpation
• Palpate radial and brachial pulse and check BP if not
already done
• Measure JVP if elevated
• Palpate precordium for heave (sustained thrusting
pulsation), thrill (palpable murmur)
• Palpate for the apex beat (left 5th intercostal space, mid-clavicular
line)
• Palpate for hepato-splenomegaly
• Elicit pitting edema if pedal swelling
Percussion- not done
Auscultation
• Locate the 4 standard auscultation areas (mitral, tricuspid,
pulmonary, aortic) and auscultate
• Auscultate for heart sounds, murmurs and radiation of murmurs if
present- radiation to the carotid area- aortic stenosis, radiation to
the axilla- mitral regurgitation)
• Auscultate base of the lungs for crackles
 4. Physical Examination of the Abdomen

Expose from nipple line to mid thigh whilst covering the genitalia
Inspection
• Is abdomen moving with respiration?
• Is there any abdominal swelling?
• Is the umbilicus- inverted or everted?
• Are there distended veins or striae?
• Are there visible peristalsis or pulsations?
• Look at the shape shape-scaphoid, distended or obese?
• Are there scars or stomas?
• Any visible masses?
• Look at hernia orifices for cough impulse. Ask patient to cough
and observe
• Look for groin swellings
• Look at the genitalia for abnormalities
Palpation
Ask for areas of pain
Auscultation may be done before palpation depending on the
situation.
• Do both superficial and deep palpation whilst watching the face
for any sign of pain
• Superficial palpation- for tenderness, guarding or rebound
tenderness
• Deep palpation- for masses (liver, spleen, kidneys and others)
• Elicit Murphy’s sign- for gall bladder disease
• Elicit Rovsing’s sign, Mcburney’s sign or psoas sign- for appendicitis
• Elicit loin tenderness- for pyelonephritis
Percussion
• For gas ( there will be resonance) or solid organ (dullness)
• For fluid- demonstrate fluid thrill, shifting dullness
Auscultation
• For bowel sounds-are they absent, present or increased
• For bruits- abdominal aorta, renal artery
• Demonstrate succession splash
Digital Rectal Examination (DRE)
 REFERENCES

• Oxford Handbook of Clinical Examination and

Practical Skills: James Thomas, Tanya Monaghan
• A Color Atlas and Text of Clinical Medicine: C D
Forbes, W F Jackson
• Hutchison’s Clinical Methods
Low-Priced Edition: R Bomford, S Mason, M Swash