BP,HR,RR,Temp,BMI

E.g.patientissitting/lyingonthebedinpain/comfortablywithnopainordistress.

Apathetic,anxious,mask-face,etc.

Facemask,tattoos,medicalbracelets,etc.

E.gneglected.

Vitiligo,obviousdiscoloration,etc.

Sweet,fetorhepaticus,etc.

Koilonychia,leukonychia,onycholysis,tarstains,p.cyanosis,andclubbing

Erythemaanddeformities(ulnardeviation,musclewasting,etc.)

CheckforbruisesandIVdrugsusage

Checkandcomparebothhandsusingthedorsalsurfaceofyourhand

Tendernessaccompaniedwithclubbingindicateshypertrophicosteoarthropathy

Hairoftheouter2/3

Eyeredness,pallorandjaundice

Angularstomatitis,glossitis,centralcyanosisanddentalhygiene

Visibleveins,scars,masses,skinchanges

Preauricular

Submental

Submandibular

Tonsilar

Ant.Cervical

Supraclavicular

Scalene

Post.uricular

Occipital

Post.Cervical

Ant.,Post.,Lateral,MedialandApical

Behindthemedialepicondyle,1-4cm

Byapplyingfirmpressure

Thoracictillumbilicus,45degrees,pillowunderhead

HR,RR,Temp,BP,BMI

Sitting/laying..Comfortably/indistress

Presenceofinhalers,O2therapy,etc.

Audiblesounds

Tarstaining,clubbing,P.cyanosis,discoloration(yellownailsyndrome)

Thenarmusclewasting,erythema

FineandFlapping

Comparepalmwithforearm

Tenderness(Hypertrophicosteoarthropathy)

Swellings,plethora,(pallor,jaundice,ptosis),(C.cyanosis,dentalhygiene,smell(smoker))

AssessJVP,cervicalLNs,accessorymuscleuse

Chestdeformities,patternofbreathing,symmetry,shape

Scars,swellings,visibleveins,skinchanges//Intercostalmuscleretractions//Hairdistribution//Axilla

Tug

Cricosternaldistance

Deviation

Palpablemassesordeformities

Tenderness

SubQemphysema

Apex,clavicle,2nd-6thribinAnt.//6thand8thribinlateral

5-8cm,ifless=pneumoniaorpneumothorax

Bronchial/vesicular

Wheezecanbepolyphonic(asthma),andmonophonic(mass)

Cracklescanbefine(pulmonaryfibrosis)orcoarse(bronchiectasis)

LethimsayE,ifheardasAthisindicatesconsolidation

Examinepittingedemaoversacrumandlumbar(RHF)

Ascitesandhepatomegalyseenincorpulmonale,RVhypertrophyandRVHF

LowerlimbsforsignsofDVTanderythemanodosum(sarcoidosis)

At45degrees,exposedfromthewaistandup

HR.RR,temp,BMI,O2sat

HTNcanbe:essential,secondary(<1%),orwhite-coatsyndrome

Patient'spositionandobviouscyanosis

Tobaccostain,p.cyanosis,clubbing,splinterhemorrhage

Tendonxanthoma,petechialrash

Palmarerythema,creasepallor,OslernodesandJanewaylesions

IVdruguseandtremor

Temp.,wet/dry

Xanthelasmata(periorbital)

Petechialhemorrhage,pallor,jaundice

Cornealarcus

HTNorDMchangesandRothspots

Malarflush(mitralstenosis)

C.cyanosis,dentalhygiene

-Diffuseinwardmovement-Twowavesperpulse

-Impalpable-Compressattherootoftheneckitwilldisappearwithpressure

-Varieswithrespiration(-withinspiration)-Lyingflat(+)-Abdominojugularreflux(+)

Betweentipofvisiblepulsationandthesternalangle//Unit:cmH2O

Venoushum

45degreeswiththeshouldershorizontal,exposetillthewaist

Chestshape,symmetry,breathingpattern,deformities

Hairdistribution,skinlesions,scars,visibleveins,skinchanges,apexbeatwithatorch

Askthepttorolltotheleftifitcan'tbefelt

Usingtheheelofthehandwhilethepatientholdshisbreathonexpiration

Usingthepadsofthefingers

Aorticarea:R-2ndICS

Pulmonaryarea:L-2ndICS

Mitralarea:apex(5thICS,mid-clavicularline)

Tricuspidarea:L-4thICSclosetotheleftsternalborder

Erb'spoint:L-3rdICSclosetotheleftsternalborder

ClosureofMV&TV,bestheardattheapex

ClosureofAV&PV,bestheardatlowerleftsternalangle

Earlydiastolic:'To-Ron-To',bestheardwiththebellattheapex.

Latediastolic/presystolic:'Ken-Tuck-Ky',bestheardwiththebellattheapex

Suddenopeningofastenosedvalveinearlydiastole(mostlyMS).Itisbestheardwiththediaphragmattheapex.

Suddenopeningofastenosedvalveinearlysystole(congenitalaorticorpulmonarystenosis).BestheardwiththediaphragmattheupperR/Lsternalborders.

Mostlyfrommitralvalveprolapseinlatesystolic.Bestheardwiththediaphragmattheapex.

Pericardialrub(frictionrub)isacoarsescratchingnoisebestheardwiththediaphragmwhileholdingbreathonexpiration.

Pleuropericardialrub

Gasinthepericardium(pneumopericardium)

Metallicsoundatsystole'S1'andaloudopeningsnapatdiastole'S2'.

Metallicsoundatdiastole'S2'andaloudopeningsnapatsystole'S1'.

HeartSoundsAuscultation

Auscultatethe4areas

AuscultatethecarotidbilaterallywhilethepatientholdshisbreathforASejectionsystolicmurmurradiationandcarotidbruits

AuscultatetheleftaxillaforMRradiation

AuscultatethetricuspidareaforTS

AuscultatetheapexforS3,S4andMS

Keepingthebellontheapex,askthepatienttoturntotheleftformid-diastolicMSmurmur

Usingthediaphragm,askthepatienttoholdhisbreathonexpirationandleanforwardwhileauscultatingtheaorticareaandErb'sareaforAR

HeartMurmurs

Determinewhetheritssystolicordiastolic

AR,PR

MS,AR(AustinFlint)

MSinapatientwithsinusrhythm,atrialcontractioncauseapresystolicaccentuationofthemurmur

Patentductusarteriosus

Harsh,blowing,musical,rumbling,high/lowpitched

MRpansystolicmurmurs->leftaxilla

ASmurmur->rtuppersternaledge,suprasternalnotchorcarotidarteries

VSDmurmurs->rightsternaledge

Exposebelowthewaistcoveringthegenitals.Askthepatienttofirstlieflat,dependentposition,thensupineelevated45degrees

BP.temp,BMI,O2sat,pulses(radial,brachial,carotid)

Tarstains,p.cyanosis,discoloration(Raynaud's)

Nailspittingandcalcinosis

Musclewastinginbothpalmaranddorsalaspects,tendonxanthoma

Amputations

Cornealarcusandxanthelasma

Ptosisandpapillarychanges(HornerSyndrome)

Hoarseness,visiblepulsation

Dilatedveins(axillay,subclavian)andJVP

Visiblepulsation(epigastricregion),skinmottling,stretchmarks(signsofwtloss)

Palpatetheepigastricregion(aorticaneurysm)andbelowtheumbilicus(iliacaneurysm)

Overabdominalaorta

Onycholysis,fungalinfectionb/wthetoes

Discoloration,dilatedveins,scars,masses,venousguttering

Hairloss(pattern),shinyskin,brittlenails

Ulcers(site,size,margin,depth,baseandsurroundingskin)

Ischemicchangesoftheheel(pressuresores)

Tendernessandtemperature(ankle,calf,thigh)bilaterally

Pulses(femoral,popliteal,post.tibialanddorsalispedis)

Capillaryrefill

1-Ptlyingsupine,fromthefootofthebed.2-Raisept’sfeet&supportlegsat45°for2–3minutes.3-Watchforpallorwithemptyingor‘guttering’ofsuperficialveins.4-Askpttositup&hanghislegsoverbed’sedge.5-Watchforreactivehyperemiaondependency.=>Lossofpallor&spreadingrednessarepositivesigns.

Flatwith1-2pillowsunderthehead-extendedarmsandlegs,exposedfromthexiphisternumtothesymphysispubis

BP,Temp,Pulse,RR,BMIandAutoSat

Commentontheweightandpain/distress

Clubbing,koilonychia,leuconychia,tarstaining

Palmarerythema,Dupuytren'scontracture,Musclewasting

Fineandflapping

Jaundice&Pallor

Xanthelasma

Ulcers,C.cyanosis,dentalhygiene,fetorhepaticus

Beefytongue,angularcheilitis,atrophicglossitis,

Cervical,axillaryandinguinal

Breast(atrophy/gynaecomastia),hairdistribution,scratchmarks,andspidernaevi

Abdomenshape,symmetry,umbilicus,andpatternofbreathing

Stria,stomas,scars,swellingsandscratchmarks.

Visibleveins,pulsationorperistalsis

Forhernias

Fordivaricationofrecti

Masses,tenderness,andguarding

Masses,tenderness,andguarding

ApplypressuretotheRIFusingthefingersthenquicklyremovethemandaskforpain

Askthepatienttobreatheoutandthenplaceyourhandbelowtherightcostalmarginatthemid-clavicularlinetopalpatethetipoftheGB

PlaceyourhandintheRIF,askthepatienttotakeabreathasyoumoveupwards1cmeachbreathuntilthemarginoftheliverisfelt

Percussfromthe2ICS(resonant)anddownwardsuntilreachingtheliver(dull)whilethepatientsholdshisbreathonexpiration.Theliverspanisb/wthispointandthepalpatedliveredge'spointinthepaststep.

PlaceyourhandintheRIF,askthepatienttotakeabreathasyoumovediagonally1cmeachbreathuntiltheMid-axillaryline.Thenaskthepatienttorolltoyoursideandredothemaneuver.

PercussstartingfromthemidaxillarylineRIFandmovediagonallydownthemarginuntilthenotechangesfromtympanictodull

Bimanual:Palpatebelowthecostalmargintofeelthekidneyswhiletheotherhandisattherenalangle.

Ballutmentpalpationisdonebyplacingonehandintherenalangle,behindthepatient,andpush,whiletheotherfeelsthekidneybelowthecostalmargin.

Hitattherenalangles

Startfromabovetheumbilicusandgodownalittle

Percussfromtheepigastricregionandmovedownwardsuntilhearingthehighesttympanicnote.Thenmovetotherightuntilyouheardullness.Askthepatienttorolltotheotherside,ifthenoteremainsdullthenthere'snoshifting.

Placethepalmofyourlefthandflatagainsttheleftsideofthepatient’sabdomenandaskthepatienttoplacetheedgeoftheirhandinthemidline(preventingtransmissionthroughtheskin)thenflickafingerofyourrighthandagainsttherightsideoftheabdomen.

UsingthediaphragmattheRIFforbowelsoundsfor4s

2cmabovetheumbilicusforaorticbruits,thenmove1cmlaterally(rightandleft)forrenalarterybruits.

Overtheliverandspleenforfrictionrubs

Cranial Nerves

▪ Optic Nerve

1- Inspect

▪ Periorbital edema

▪ Eyelids: proptosis, ptosis, lid lag and retractions.

▪ Conjunctiva: chemosis

▪ Sclera: redness

▪ Pupil: shape and symmetry at rest, pupillary reflex, RAPD, accommodation, anisocoria.

▪ Cornea: ulceration using fluorescein strips.

2- Palpate eyes’ orbits for masses

3- Homonymous defect

4- Sensory inattention

--------------------------------------------Cover one eye for the next steps----------------------------------------------

5- P. visual field (wiggling finger, white hatpin, red hatpin)

6- Color desaturation using a red hatpin

7- C. visual field using a red hatpin

8- Blind spot

-------------------------------------------------------Just mention----------------------------------------------------------

9- Test acuity using Snellen

10- Test color vision using Ishihara plates

11- Test macular function using Amsler grid

12- Fundoscopy for retinopathies

▪ CN 3,4,6

1- Draw an H for nystagmus

2- Pupillary reflex

▪ Vestibulocochlear

Whispered voice test

Weber’s test

Rinne’s test

▪ Trigeminal Nerve

Sensory: Touch, pain, common sensation from ant. 2/3, nasal tickle

Motor: mastication muscles weakness (temporalis, masseter), palpate masseter, open mouth against resistance

Reflexes: corneal, jaw jerk

▪ Facial Nerve

Sensory: taste from ant. 2/3

Motor: asymmetry (nasolabial folds, eyelids, forehead wrinkles), involuntary movements, raise eyebrow, show teeth,

shave (platysma), 2 resistance (eye ‘oculi’, cheeks ‘buccinator’)

Reflexes: corneal

▪ Glossopharyngeal Nerve

Sensory: common sensation and taste from pot. 1/3

Motor: palate ‘Ah’ (uvula deviation), air escape from the nose, bovine cough, swallow test

▪ Accessory Nerve

Trap and SCM, (inspect asymmetry or wasting), (palpate), (against resistance)

▪ Hypoglossal Nerve

Inspect tongue (wasting, fasciculations, involuntary movements)

Put tongue out (deviation, involuntary movements) // Side to side // Tongue against resistance

Say LaLaLa // Swallow test

-----------------------------------------------------------------------------------------------------------------------------------------

Motor

▪ Inspect: asymmetry, deformity, abnormal movements (tremors, myoclonic jerks, fasciculations)

▪ Palpate: bulk (hypertrophy, wasting), tenderness, symmetry

▪ Tone: UL, LL (roll, then briskly lift the leg), ankle clonus

▪ Power: UL, LL, pronator drift

▪ Reflexes: deep tendon, superficial (abdominal, cremasteric, plantar), Hoffman’s, finger jerk and primitive reflexes.

-----------------------------------------------------------------------------------------------------------------------------------------

Coordination

▪ Stance and gait: normal, tandem, Romberg’s

▪ Eyes: Nystagmus

▪ Speech: dysarthria, staccato

▪ Upper Limbs: tone, reflexes // Finger-to-nose (dysmetria, intention tremor or dyssynergia), rapid alt movement (dysdiadokinesia),

rebound phenomenon

▪ Lower Limbs: tone, reflexes // Heel-to-shin

-------------------------------------------------------------------------------------------------------------------------------

Sensory

▪ Touch, Pain, Temp

▪ Vibration, joint position

▪ Stereognosia, graphaesthesia

▪ Point localization, sensory inattention

Comment: normal power/tone

Sitting,exposedabovetheclavicle

HR,BP,Pulses,-Sinus-Rhythm,BMI,Temp,RR

Weight(loss,gain,normal)//Agitation,restlessness,apathy//Speech(hoarseness,slow,pressured)//Tachypnea

Vitiligo

Thyroidacropachy,brittlenails,onycholysis,clubbing

Palmarerythema,carpaltunnelsyndrome,musclewasting

Wet/sweatyorcold/dryhands,Finetremor

Sweaty/drycoarseskin/hair,hairlossfromtheouter2/3oftheeyebrows,preorbitalpuffiness

Redness,chemosis,ulcers,conjunctivitis,lidretractions

Opthalmoplagia(drawanH),lidlag,proptosis

Macroglossia(tonguethickening)

Inspect,askthepatienttoextendhisneck,swallowandprotrudethetongue.

Comment:•Symmetrical,withnomasses(thyroglossalcyst)orscars.•Movesupwardwithswallowing.

Lookatthebackofthetongueforlingualgoiter

Pembertonsign

Palpatetheneckwhileslightlyflexed,askthepatienttoswallowandprotrudethetongue.

Comment:•Symmetrical,normalshapeandsize,regularmargin.•Smoothwithnothrillsorhotness.•Nomasses(thyroglossalcyst)ortenderness-whetherdiffuseorlocalized.•Movesupwardwithswallowing.

Trachealdeviation

CervicalLNs

Manubriumdirectly

Auscultatetheglandforbruitusingthebell

Examinetheirmotorthensensorysupply'attachedpic.'

Papertestforadducterpollicis

Hipandbelow(ormid-thighandbelow)

Posture,Symmetry,Deformities(varus/valgus)

Patellarposition,Musclebulk

Redness,Rashes,Bruises

Scars,Swellings,Sinuses

Gait:askthepatienttowalk

Musclebulk

Ensuremusclebulksymmetrybymeasuringthecircumference20cmabovethetibialtuberosity

Feelthepatella,patellartendon,tibialtuberosity>Femoralandtibialcondyles>Jointline>Fibularhead

Feelthequadsmusclebulk

Temp.over,aboveandbelowthekneejointbilaterally

Tendonofquadricepsforsponginessoftenosynovitis

Activekneeextensionandflexionandlegelevation

Passivekneeextensionandflexionandlegelevationfromtheheels

Applyvalgusstress(pushthelegout,kneein).Redoitafterflexingtheleg30degrees

Applyvarusstress(pushthelegin,kneeout).Redoitafterflexingtheleg30degrees

First,flexthekneeandinspectfromthelateralsideforthePosteriorsagsign

Flextheknee,sitonthefoot,placeyourthumbsonthetibialtuberosityandthenpushtheleganteriorly(ACL)thenposteriorly(PCL)

LachmanTest:placeyourkneeunderthepatientskneeandthenanteriorlyandposteriorlywithdrawtheleg

Handholdingtheheel,otheronthejointline>elevatetheleg>legflexion>legexternalrotation>abductthehip>varusstress>extend

Handholdingtheheel,otheronthejointline>elevatetheleg>legflexion>leginternalrotation>adductthehip>valgusstress>extend

Lateralforceisappliedtothepatellawiththethumb.Thenmovesthekneefromfullextensionto90degofflexionandthenreturningtofullextensionwhilemaintainingthelaterallyappliedforceonthepatella.

Commentonabsenceofobliterationofparapatellargrooves(gutter)