Surviving 4th Year:

A Guide to Clinical Medicine

Heres hoping you wont have as difficult and miserable a time as I had

By:
Methal Al-Bayat
Special Thanks to:
Amani Al-Shayea
Maha Al-Madi

You hear a lot of horror stories about medicine and some of them are true but a
lot of them are exaggerations and its these stories that made me absolutely hate
this course (along with the feeling that everyone else seemed to be learning and
making good progress except me), but really I didnt have to be that scared (just
a little bit scared is enough ). So, here is the advice and teachings I wish I had
known before I started the course, hope they are of some help.
You will notice that I focus mainly on physical examination; that is because there
are a lot of notes on history taking that are very good, and most doctors will focus
mainly on history and will completely ignore the physical examination part or if
they do take the time to show you how to examine, there will be so many of you
that you will not be able to really see or understand what is going on (that was
the main problem for me I can hear what the doctors say but with 11 other girls in
the group I could never really see what was going on).
At the end, I added my surgery case report to give you an idea of how to
comment on the history and physical examination. Remember that in medicine
you are required to go into much more detail than in surgery, so dont follow my
case report exactly in medicine but it should give you some idea of how to
comment on normal findings.
General Advice
Nicholas or Macleods? A very controversial topic, everyone has an opinion,
here Ill try to write the pros and cons of each book
Nicholas
Macleods
Looks scary
Looks friendlier
A LOT of information
Lacking information (not everything in
Not many pictures
Nicholas is mentioned in this book)
A LOT of picture and colors
Very boring (sometimes
Shows how to perform some physical
difficult to read)
Most doctors prefer it
examinations
th

Not all the doctors follow it (a lot of

Usually it is enough for 4
them havent even read it)
year
This years OSCE came from the
pictures here
Personally, I preferred Nicholas, the tables in it are VERY good (I tried to
incorporate as many tables as I could in here) and overall it is a very
comprehensive book (If you have time try to read both books)
Something that would really help is if you begin reading in the 1 st semester
during BCS and try to memorize some of the tables in Nicholas
Equipment (that you cant be without)
o
Sphygmomanometer (you can borrow one from the hospital, but I
prefer to have my own)
o
Pen torch
o
Tongue depressors (sterile)

Ruler
Stethoscope
Measuring tape
Alcohol swabs
Cotton swabs
Tooth picks
The topics that you ABSOLUTELY have to know for your clinical exam are
o
SCD
o
Bronchial Asthma
o
COPD
o
Chronic Liver Disease
o
DM & HTN (although you will never get a patient in the exam with
only these complaints but you MUST know them)
o
IBD (Ulcerative Colitis and Crohns Disease)
o
Pneumonia (and Para pneumonic lesion)
o
DVT
The topics that you should know
o
Thalassemia
o
Tb
o
MI
o
Pleural Effusion
o
Lymphadenopathy
o
Diabetic Ketoacidosis
The above are the most common topics that you might get in the oral exam
but of course if they dont have enough patients some unlucky students will
get difficult cases as Neuro and Renal but usually the doctors are nicer to
the students who get difficult cases
In the end you have to remember that taking a good history, knowing some
basic information, and performing a good physical examination (even if you
dont catch all the findings, the way you do it is more important) will get you
a passing grade
Each doctor has a specific way they want you to follow in history and
physical examination and very rarely two doctors will agree on the same
method so in the end do what you are most comfortable with.
Before starting the course I would advise you to look for an older STUDENT
to teach you how to do a basic physical examination and take a history. In
my opinion it is best to learn the basics from a student or an intern because
the information and the method will be fresh in their minds and at the end of
the course youll find that the best teachings are those given by your fellow
students because they will be thorough and they will teach you everything
(residents and consultants are either too busy to give you a complete
teaching, too tired of teaching, or give you a lot of information that will be
confusing and beyond your level, but dont get me wrong some residents
give EXCELLENT teachings and some students may teach you something
incorrect, but with me the students gave me the best teachings)
o
o
o
o
o
o

Try as hard as you can to get someone (a student or intern) to give you
teachings of the major systems (CVS, Resp, & GIT) BEFORE you start the
course so that you can get as much benefit as you can
Try to be active and depend on yourself, starting from the 1 st day, go to the
nurses station and look at the patients list; find a simple case and one that
you would expect to have good physical findings and go take history and
perform a physical examination & try to choose a case that matches the
specialty of the consultant who will give you a bed side teaching that day.
From the very beginning try to teach yourself how to take a history in 30 min
and perform a physical examination in 20 min, you will need to practice this
skill so that you will be prepared in your final (some of my friends were only
allowed 40 minutes to take the history and do the physical exam, I dont
mean to scare you but you have to be prepared for anything)
Learn the basic formula for history taking by heart so that you only need to
take notes while the patient talks and then read your history from these
notes without organizing it (in your final you will not have time to organize
your history, you will have to present it to the doctors from your notes so
PRACTICE, PRACTICE, PRACTICE). My advice to you is never rewrite
your notes so that you will learn how to read a history from your chicken
scratches and this practice will pay off in the final.
Try to present a case in front of a doctor, this will need coordination with the
rest of the members of your group, try to work out a schedule with the group
deciding who will present a case each day, this way everyone will have a
chance to present and there wont be one person who presents every time.
When you are presenting your case or having a discussion with your friends
or with the consultant in front of the patient, speak in English and NOT in
Arabic because you might be talking a bout a disease that the patient does
not have but he might think that he has it.
Read Dr_Kindys notes. They are in my opinion the best notes on history
and physical examination. They are very comprehensive but you may like to
add some of your notes to them (from what doctors tell you and from what
you read in books) so that when the exam comes these notes will be all you
need to revise from.. There is a note on history taking by Faisal Al-Haddad &
a note on physical examination by beauty 22 which are really good also.
Read about diseases from Al-Khurasany notes, they are also the best notes
in my opinion & the notes done by Shams Al-Turki are good also.
When presenting to a doctor NEVER EVER use abbreviations always say
the whole word e.g. dont say DVT; say deep venous thrombosis
Try to go to the hospital every day and take as many cases as you can, if
you dont feel like taking a case just watch someone else doing it, the
practice will be very beneficial.. Try to prepare ONE case a day ONLY to
avoid confusion then read about it when you go home.
Sometimes just go to the hospital and perform physical examinations, no
need to take history

Prepare cases that match your level. For e.g. sickle, respiratory or GIT
cases. Do not Prepare a case that is complicated or higher than your level
such as neurology, renal or rheumatology.
If a whole week goes by and you didnt take any cases thats ok, dont
panic, dont be worried, you need a break every once and a while, so just
try harder the next week (DONT let anyone make you feel bad because
you didnt take any cases).
If you feel like you dont know anything and it seems everyone around you
is getting better while youre just the same, DONT WORRY everyone else
is feeling exactly the same thing but no one likes to admit it
DONT pay any attention to those students who tell you about other
students who failed or about how malignant some doctors are. Just ignore
them, you will get anxious and miserable and like I said before, a lot of the
stories are exaggerations.
In the end, practice is what matters, and if all else fails just act like you
know what youre doing, be confident, and dont hesitate.

History
This is the basic formula for history (remember, each doctor will have a certain
order that he or she prefers and they will always find fault with your history, so
dont get depressed).
ID
o Name
o Age
o Marital status
o Nationality
o Residence
o Occupation
o Religion (as some diseases are related to religion).
Chief Complaint (CC)
o
What is the patient complaining of
o
Duration of complaints
o
Admitted through the ER or OPD?
o
Date of hospital admission
o
Who brought him or her to the hospital.
History of Presenting Illness (HPI)
o
There are two scenarios
a. Chronic disease that is related to the CC (you say the patient is
a known case of)
i. When & where the patient was diagnosed
ii. Treatment
iii. Compliance
iv. Control (i.e. is the disease being controlled by the current
medications and their doses?)
v. Complications (of the disease)

When the patient was last (i.e. when the symptoms 1 st appeared
in life)
i. What were the symptoms at the time they 1st appeared (are
they different from what the patient presents with now?)
ii. What was the patient doing at the time they appeared
iii. Mode of onset (sudden or gradual).
iv. Continuous or intermittent
v. Duration.
vi. Character
vii. Site & radiation
viii. Precipitating factors
ix. Aggravating factors
x. Relieving factors
xi. Severity
xii. Frequency
xiii. Progression & if & when a change occurred
o
ER or OPD admission
a. When & where
b. Complaint
c. Management & treatment received
o
Frequency of ER admissions (related to the CC)
o
Last ER visit or admission & duration of stay
o
Frequency of ICU admissions (related to the CC)
o
Last ICU admission, duration of stay, management & diagnosis
o
Cardinal symptoms of involved system
Past History
o
Past medical history
i. Ask specifically about DM, HTN, and bronchial asthma
ii. When & where diagnosed
iii. Treatment & compliance
iv. Control (are medications controlling the disease?)
v. Complications
o
Past surgical history
i. What was the operation?
ii. When
iii. Where
iv. Complications
o
Blood transfusions
i. Frequency
ii. Amount
iii. Complications
iv. Vaccinations given for blood transfusions.
o
Trauma
Drug & Allergies History
o
Name
o
Dose
b.

When started
Physician or self-prescribed.
History of allergies to food or drugs
Family History
o
Parents

Are they relatives?

Ages

Any diseases

If they are dead what was the cause of death

o
Siblings

Any similar illness?

Social History
o
Education & occupation
o
Smoking

Passive or active

Type of smoking

How much/day

For how long

o
Alcohol or drug use
o
Living and marital status
Immunization History
Menstruation History (for females)
o
Age of menarche
o
Regular cycle or not
o
Duration of cycle
o
Any associated symptoms (dysmenorrhea or menorrhagia).
o
Date of last menstruation
o
Pregnancy

How many pregnancies (how many live & how many stillbirths
or abortions?)

Complications during or after

Type of delivery
Systemic Review
o
General

Well being

Appetite

Weight change

Energy

Sleep

Mood
o
Nervous System

Headaches

Dizziness

Faints

Altered sensations (numbness or tingling)

Weakness
o
o
o

Visual disturbance

Hearing problems (deafness, tinnitus)

Memory & concentration changes

Respiratory System

Dyspnea or shortness of breath (on exertion?)

Cough

Wheeze

Sputum production (color, amount, & character)

Hemoptysis

Chest pain associated with inspiration or cough

Cardiovascular System

Chest pain on exertion

Dyspnea on exertion & how much exertion

Orhopnea

Paroxysmal nocturnal dyspnea

Palpitation

Claudication

Ankle edema
Gastrointestinal System

Oral ulcers

Dental problems

Dysphagia

Nausea & vomiting

Hematemesis

Indigestion

Heartburn

Abdominal pain

Change in bowel habit

Change in color of stool & consistency

Genitourinary System

Dysuria

Change in frequency

Nocturia

Hematuria

Incontinence

Hesitancy

Poor stream or flow

Terminal dribbling
concerns men

Urethral discharge

Abnormal bleeding

Vaginal discharge
concerns women

Contraception
Musculoskeletal System

Joint pain, stiffness, or swelling

Mobility

Falls

Endocrine System

Heat or cold intolerance

Change n sweating

Polydipsea
o
Hematological System

Bruising

Fevers, shivers & shakes

Bleeding

Lumps

Blood clots in legs or lungs

o
Skin

Skin rashes
Remember to go into as much detail as possible, after all history is the
most important part of your examination
You will have to modify the questions as you go along but the above is the
basic formula to follow
Once you reach systems review DONT mention the involved system
because you already went into detail about it in HPI
A way to assess severity of pain is to ask the patient to grade the pain on
a scale of 1-10, 1 being mild & 10 being the worst pain the patient has
ever experienced
If there is claudication dont forget to ask about claudication distance
(VERY VERY IMPORTANT)
If there is any change in the symptoms the patient has ALWAYS get a
time-line (what started 1st, when did it change, were the 2 symptoms
present together?)
ALWAYS ask about any diurnal variation in the symptoms (e.g. fever or
sputum)
If there is sputum production dont forget to ask about the position of the
patient which increases it
If the patient had some investigations done before, ask about the results
and if there was a follow-up appointment
NEVER make any assumptions, say exactly what the patient said and if
you think you know what the patient meant say most probably... (e.g. a
sickler tells you that he takes a small yellow pill every day, DONT say the
patient takes Folic Acid, instead say the patient takes a small yellow pill
every day most probably Folic Acid)
If the patient was given medications (for the same presentation) before
coming to you ask whether there was any improvement with the
medications
ALWAYS ask if there were any similar episodes in the past
In HPI DONT forget to mention pertinent negatives (i.e. the negative
symptoms are just as important as the positive ones)
If you suspect the patient has a certain disease ALWAYS ask about the
risk factors and mention them (the positives and negatives) in HPI
o

In social history, ask specifically about the housing conditions: is it a house

or an apartment? Is it owned or rented? How many floors? How many
rooms? How many people per room? Carpeting? Pets? ...
ALWAYS know why you are asking the question (a lot of times the
examiner will interrupt you in the middle of the history and ask you why did
you ask the patient that question, so ALWAYS know the reason behind the
question)
DONT forget to mention the hospital course (i.e. what happened to the
patient after he/she was admitted, the progression of the symptoms,
treatment, investigations)
DONT FORGET TO PRACTICE, PRACTICE, PRACTICE!!!!

Physical Examination
Again, here is the basic formula. Remember, there is no right way of performing
a physical examination; everyone has their only method, so experiment with
different ways until you find a way that you are most comfortable with, however,
some doctors will never agree with your method and will insist that their method
is the right way.
Remember that when a doctor asks you to inspect a system you start from the
general inspection all the way down to the lower limbs, but if asked to inspect a
specific thing e.g. the abdomen you only examine the abdomen
ALWAYS stand at the right side of the patient (except when inspecting, you must
stand at the foot of the bed so you can compare both sides). Sometimes the
patients bed is against the wall in a way that prevents you from standing at the
right side, you MUST move the patients bed so you can stand at the right side.
General inspection
o
Young, middle-aged, elderly
o
Gentleman or lady
o
Lying, lying comfortably or sitting up
o
Connected (or not connected) to IV line, blood, saline or heparin
lock, or oxygen (BE CAREFUL Dr. Akhtar HATES this part & he
doesnt want to hear it)
o
Well-developed & well-nourished (or under developed &
undernourished; when talking about development we mean does
the patient look his or her age [thalasemia patients look younger
than their actual age]. Nourishment refers to the patients weight
[normal, obese, or cachectic [in cachectic patients there will be a
prominent zygomatic arch])
o
Conscious and alert (or drowsy)
o
Not in obvious pain or respiratory distress (or is in obvious...)
o
Not obviously pale nor jaundiced (or appears...)
o
Not obviously cyanosed (or appears...)
*always say appears in general exam so as not to fall in a trap e.g. if
the patient looks jaundiced say he appears to be jaundiced but I will
make sure by checking his sclera
Hands (ALWAYS compare the two hands)
10

Nails
Look at their color (white, yellow...)
Look for peripheral cyanosis

Look for pallor in the nail-beds

Check capillary refill: press the nail and watch the nail bed
become pale then release the pressure and watch the nail
bed go back to its normal color, it shouldnt take more than 2
seconds if it takes longer it is abnormal, check all 10 fingers

If the patient has henna or nail-polish on, you cant comment

on anything about the nails
Fingers

Look for finger clubbing

Grades
1. Loss of angle check by lifting the finger until it is at
eye-level and then look at the angle between the nail
and the nail-bed if the angle is obliterated the patient
has grade I finger clubbing
2. Fluctuation (there is a nice picture in Macleods
showing how to do this) by placing your thumbs (of
both hands) on the sides of the nail with your index
fingers on the back of the back of the patients finger
and press one thumb to the side of the patients nail
and feel for a fluid-like feeling with your other thumb
then alternate pressing and feeling
3. Drum-stick appearance there is increase in the
vertical and horizontal curvature of the nail
4. Hypertrophic pulmonary osteoarthropathy check
for tenderness at the wrist and X-ray to confirm

Joint deformities

Feel for any nodules

Look for ulcers

Dorsum

Feel for the temperature

Look for tendon xanthomata (type II hyperlipidemia)

Pulps of fingers

Ulcers

Nodules
Palms

Jaundice

Pallor (look in the palmer creases)

Palmer xanthomata (type III)

Excessive sweating

Palmer erythema (look for redness in the thenar and

hypothenar eminences; if it is very red raise the patients
hand above the level of the heart and if the redness

11

disappears the patient doesnt have palmer erythema but if

the color remains then the patient has it)
o

Wrist

Tenderness
Joint deformity

Tremors
o
Fine: ask the patient to hold out the hands parallel to the ground,
palms down with the fingers spread. Put a piece of paper over the
hands and look for any tremors
o
Flapping (asterixis): ask the patient to extend the hands as though
he/she is pushing a wall with the fingers spread and wait 15 sec for
the tremors to start spontaneously, if they dont, induce it by doing
the following:
1. hold the arm from the forearm NOT the wrist with your left hand
2. With your right hand swipe the patients hands with a gentle
force (so that you are trying to increase the extension of the
hands) one at a time starting from near the wrist and moving
upward to the fingers. Dont do it too fast or too slow. (This is
very hard to explain, have someone show you how to do it!)
Pulse
o
Describe the following from the radial pulse
1. rate (count for 15 sec & multiply by 4 or count for 30 sec &
multiply by 2) *remember normal range is 60-100 beats per
minute
2. rhythm (regular or irregular)
3. volume
4. condition of the vessel wall
5. check for radiofemoral delay i.e. compare between the radial
pulse and the femoral artery
6. check for synchronization with the pulse of the other arm
7. Usually you cant tell the character of the pulse from the radial
artery you have to go to a bigger artery as the brachial or better
yet the carotid artery (and really no one can tell what the
character is, just say normal character and if the doctors start
asking questions just say it feels just like your own pulse)
8. check for collapsing pulse

feel the radial pulse with the pulps of the fingers of your right
hand (pressing a little more firmly than you usually would)

hold the patients forearm with your left hand and lift it over
the level of the patients heart making sure it is straight

if you feel the radial pulse beating against your fingers, the
patient has a collapsing pulse (remember that if there is
collapsing pulse then the pulse is high volume)
Arms
o
Look for bruising, ecchymosis, scratch marks, pigmentation,
discoloration or in other words dont forget to inspect the arms

12

Remember to compare both arms

Blood pressure
o
Korotkoff sounds
I. K I is the pressure at which a sound is first heard over the
artery (the systolic pressure)
II. K II is the increase in the intensity of the sound as the cuff is
deflated
III. K III is the decrease in the intensity of the sound
IV. K IV is the muffling of the sound
V. K V is the disappearance of the sound (the diastolic pressure;
however it slightly underestimates the arterial diastolic blood
pressure, but in K IV is more accurate if there is severe aortic
regurge and sometimes K V is absent in normal people and K
IV must be used)
Head & neck
o
Inspect the head and neck commenting on any obvious
abnormalities (e.g. xanthalasma, swellings in the face and neck...)
o
Mention any obvious pallor or cyanosis
o
Eyes

Check for pallor by asking the patient to look up and pulling

the lower eyelids down and looking underneath them and
comparing their color with the color of your thumb nail beds

Check for jaundice by asking the patient to look down while

you pull their upper eyelids and look at the sclera for a
yellowish discoloration. DONT FORGET TO OPEN THE
CURTAINS FOR DAYLIGHT BEFORE DOING THIS.

Look at the iris for any abnormalities (e.g. arcus senalis or

cornealis)
o
Nose

Look up the nose with a torch to find any polyps,

engorgement, or deviated septum (I personally never looked
up anyones nose but Dr. Mona once told me off for that)
o
Mouth

Using a torch and tongue depressor comment on

1. Oral hygiene
2. the condition of the gums (if there is bleeding or
hypertrophy)
3. Any tongue abnormalities (macroglossia or
geographical tongue)
4. Pallor (by looking at the mucous membranes)
5. Jaundice (by looking under the tongue)
6. Cyanosis
o
Sinuses (I have no idea how to check them and I never did but Dr.
Mona also told me off for not checking them). However, they can be
examined by pressing the pulps of your fingers over the sinuses
(frontal, ethmoid and sphenoidal air sinuses).
o

13

Neck

Look for any obvious swellings

Check the carotid pulse below the angle of the jaw pressing
against the sternocleidomastoid
Check the jugular venous pressure

Ask the patient to lie at 45

Locate the internal jugular vein (starts between the

two heads of the sternocleidomastoid then goes
behind the muscle then medial to it and comes below
the jaw and behind the earlobe)

To make sure that the vein doesnt go above the

earlobe ask the patient to sit up at 90

Find the highest area of pulsation of the vein and put

a pen at that point parallel to the ground

Place a ruler (preferably a see-through one) at the

sternal angle perpendicular to the ground (not the
patient, the ground) the sternal angle is the zero-point

Find where the pen and the ruler meet and then add 5
to that number and you have the jugular venous
pressure (measured in cm of water)

The normal jugular venous pressure shouldnt be

more than 3 cm above the zero-point
Check the lymph nodes on both sides of the neck (usually all
of them from behind the patient, but Dr. Mona says
differently)
1. Submental below the chin
2. Submandibular below the angle of the jaw
3. Pre-auricular right in front of the ear
4. Post-auricular right behind the ear
5. Anterior cervical in front of the sternocleidomastoid
muscle (remember NEVER palpate both sides at the
same time as you may induce a vasovagal attack)
6. Supraclavicular above the clavicles (left
supraclavicular is Virchows node if there is gastric
carcinoma)
7. Infraclavicular below the clavicles (scalene nodes,
they enlarge if there is lung carcinoma)
8. Posterior cervical behind the sternocleidomastoid (Dr.
Mona says they should be palpated from in front of
the patient and again NEVER palpate both sides at
the same time)
9. Occipital at the base of the skull you palpate them
with your thumbs (while your fingers are pointing
towards the patients ears)
Check the position of the trachea by pressing your finger in
the sternal notch backwards to find the trachea and see if it

14

is centrally located (if it slightly displaced to the right that is

normal)
Palpate the thyroid gland from behind the patient with the
patients head slightly flexed (if the thyroid is normal you will
not feel anything, no one in medicine taught us how to
palpate the thyroid and no one asked us about it except Dr.
Mona, so I really dont know how to explain this to you)

Back
o
o
o

Since the patient is already sitting up examine the back before

moving on to the chest
Ask the patient to sit up and cross his or her arms and hold up their
gown
Inspection

Spinal deformities

Scars

Swellings

Chest movements
Palpation

Before doing this ask the patient if there is any tenderness

and if there is start palpating away from the tender area and
then palpate the area last

While palpating ask the patient to tell you if there is any

tenderness

Feel for subcutaneous emphysema (which is air in the

subcutaneous layer and gives a crackling sensation on
palpation)

Press against the vertebrae to see if there is any tenderness

Check the chest expansion by encircling the back with your

hands (with the thumbs towards the vertebra and the rest of
the fingers towards the chest) and right before you bring the
thumbs together ask the patient to exhale and while he does
that bring your thumbs together and then ask the patient to
take a deep breath and watch your thumbs move apart
(normal expansion is 3-5 cm)

Palpate tactile vocal fremitus by placing your hand on the

back (avoiding the scapula) and ask the patient to say 99 in
English or 44 in Arabic and feel the vibrations then compare
with the corresponding area on the other side
Percussion (this is where it is important to keep the patients arms
crossed because it will keep the scapulas apart)

Percuss at the edges of the scapulas start with your fingers

parallel to the vertebra for the 1st two sets of percussion then
keep your fingers perpendicular to the vertebra

There is a nice picture in Nichols which shows you where to

percuss

15

Remember to compare both sides at each percussion i.e.

you start percussing from the left then you move to the same
area on the right then go to the next area below that (still on
the right side) then move to the same area on the left side
(so you move like this

Tidal percussion (only Dr. Mona mentioned this to us, and I

couldnt find it in any book, this is what I understood from her
but please MAKE SURE OF THE CORRECT WAY TO DO
THIS) before starting ask the patients permission to draw
marks on him

Percuss in the mid-clavicular line from the back (is it

called the mid-clavicular line? Im not sure; but it
should correspond to the mid-clavicular line in the
back)

Percuss downwards until you reach an area of

dullness and keep your finger over the area

Ask the patient to take a deep breath and hold it

Percuss from the previously dull area downwards until

you find the new area of dullness

Mark the area

Ask the patient to exhale completely and hold his

breath

Percuss upwards until you find the area of resonance

Mark it

Measure the area, normally it is 5 cm (I think)

Repeat on the other side of the chest

This is done to check for any diaphragmatic paralysis

On the right side the liver interferes with it (but Im not

exactly sure what it does to change the value)
o
Auscultation

Place your stethoscope at the same areas of percussion and

listen to breathing of the patient (the quality of the breathing
[bronchial or vesicular] and the air entry

Then go back and place your stethoscope at the same areas

of percussion again and ask the patient to whisper 99 in
English or 44 in Arabic and listen to the vocal resonance
(vocal resonance and tactile vocal fremitus go hand in hand,
if one is reduced the other will also be reduced NEVER say
that one is reduced and the other is normal)
Chest (remember here you are examining both the lungs and the heart)
o
Inspection

Scars

Hair distribution

Distended veins, spider nevi, any discolorations

Any skeletal deformities

Obvious pulsations

16

Chest movements
o
Palpation

Ask the patient if there is any tenderness and start palpating

away from that area and leave it for last

As you palpate look at the patients face and see if he is in

pain and ask him to tell you if there is any tenderness

Same as for the palpation of the back

Also palpate the apex beat (the most lateral and inferior
point at which pulsations can be felt)

Palpate for thrills and parasternal heave (by placing your

hand on its side [with your thumb pointing outwards and your
small finger on the chest against the left sternal edge
o
Percussion

Same things as for the back (except for the tidal percussion)

Look at Nicholas for the areas you should percuss

o
Auscultation

Same things as for the back

Auscultation of the heart

Start with the diaphragm at the apex

Move to the tricuspid area at the 5th left intercostal

space at the edge of the sternum

Move to the pulmonary area at the 2nd left intercostal

space

Move to the aortic area at the 2nd right intercostal

space

Then listen at the same areas using the bell

Abdomen (proper exposure is from the nipple to mid-thigh but in our culture
it is until the symphesis pubis, make sure the patient is lying flat on his back
with his arms at his side [this is very important for proper examination]
o
Inspection

Stand at the foot of the bed

Look for movements and type of breathing

Look at symmetry of the abdomen

Look at shape of the abdomen

Look at hair distribution

Look at the shape of the umbilicus

Look for any scars

Discoloration

Visible swellings

Visible pulsations (for this you need to bend down until your
eyes are at the same level of the abdomen)
o
Palpation

1st and foremost ask the patient if there is any area of

tenderness so you can avoid it and leave it for last

Superficial palpation

17

You are feeling for rigidity, guarding, superficial

tenderness, and superficial masses

If there is no tenderness, start palpating lightly at the

right iliac fossa moving in a counter-clockwise
direction to the hypogastrium, left iliac fossa, left
lumbar region, left hypogastrium, epigastrium, right
hypochondrium, right lumbar region, and finally
umbilical region

ALWAYS look at the patients face as you palpate to

see if you are causing any pain. This is very important
and most doctors will tell you off if you dont look at
the patients face
Deep palpation

You are feeling for deep tenderness and deep masses

Palpate the same way as for superficial but applying

more pressure with your hand as you palpate
Organ palpation

The liver
Palpate the liver by starting in the right iliac fossa and
asking the patient to take a deep breath
As the patient expires move your hand upward, you
must practice the timing of your movement with the
expiration
Keep moving upwards until the edge of the liver hits
your examining hand
Make a mental note of where the lower border is and
proceed directly to percussing the liver

The spleen
Palpate the spleen by starting at the right iliac fossa
and move upwards and medially towards the
umbilicus (why do you start at the RIF? Because the
spleen enlarges inferiorly and medially)
Once you reach the umbilicus ask the patient to
breath deeply and then begin to move your hand
upward and laterally towards the left hypochondrium
timing the movement of your hand with each
expiration
If you can not feel the edge of the spleen try the
bimanual palpation by putting you left hand under the
patients left hypochondrium and pushing upwards
and palpating with your right hand as before with the
patient rolled towards the right side
If you still cannot feel the spleen try percussing
Remember the spleen has to enlarge to about three
times its normal size before you can palpate it
The kidneys

18

I honestly have no idea how to palpate for them.

However, it can be palpated by a bimanual method.
For the right kidney put your left hand below the right
flank while palpating by the right hand and vice versa.
It is easier to explain this method practically than
theoretically.
The difference between the left kidney and the spleen
1. you cannot palpate the upper border of the spleen,
while you can get above the kidney
2. the spleen has a notch
3. on inspiration, the spleen moves infero-medially
while the kidney moves inferiorly
4. the kidney is ballottable (the kidney can be felt to
move between the two hands as if it is moving in a
fluid)
5. percussion over the spleen gives a dull note while
the kidney gives a resonant note because it lies
behind loops of bowel containing gas
Percussion
The liver
Start percussing in the right iliac fossa in the midclavicular line until you reach an area of dullness
which should correspond to the lower border of the
liver
Ask the patients permission and draw a line there
Then move to the 2nd right intercostal space in the
midclavicular line and percuss downwards until you
reach an area of dullness
Keep your finger on that area and ask the patient to
inhale and hold his breath
Percuss the area again while the patient holds his
breath and if the area becomes dull then it
corresponds to the upper border of the liver
Ask permission and mark the area
Using the measuring tape measure the liver span
Normally it is 8-12 cm
The spleen
Start percussing in the right iliac fossa and move
upwards and medially until you reach the left
hypogastrium
Then percuss over Traubes area which is the area
between the anterior axillary line, the border of the 7 th
rib, the left costal margin, and the xiphisternum
Ascites
With your finger pointing downwards, percuss in the
midline of the abdomen and move to the flanks

19

Normally the abdomen is resonant but when there is

ascites there will be dullness in the flanks (fluid
accumulating there with the patient supine)
If there is dullness, check for shifting dullness
Start percussing from the midline to the left flank until
dullness is reached
Ask permission and mark the area
Roll the patient to the right side (i.e. towards you)
Wait 30 sec to 1 min
With the patient still on the side, percuss from the
marked area (the area of dullness) towards the
midline of the abdomen
The previously dull area should become resonant as
the fluid shifts towards the midline and a new area of
dullness should be found closer to the midline
Check fluid thrill
Ask the patient to place his hand at the midline of the
abdomen (with the medial side of the hand against
the abdomen), this is to stop the conduction of the
vibrations by the skin of the abdominal wall
Place one hand at the side of the abdominal wall
With the other hand flick the abdominal wall on the
other side of the abdomen
If there is massive ascites a thrill will be felt by the
opposite hand

Auscultation
Bowel sounds
Place the stethoscope just below the umbilicus and
listen to the gurgling of the bowels
Liver & spleen
Place the stethoscope over the two organs and listen
for a friction rub as the patient breathes
Venous hum
Best heard between the xiphisternum and the
umbilicus
Bruits
Heard over the liver if there is hepatocellular cancer
Heard in the renal arteries if there is renal artery
stenosis; listen on either side of the midline above the
umbilicus
Lower limbs
o
Inspection

Look for bruising, scratch marks, discoloration

Ulcers

Swellings
o

20

Varicose veins
Look at the toes for clubbing, cyanosis
Look between the toes for ulcers, infections
Look for joint deformities
Palpation

Palpate the temperature of the legs and feet

Check the capillary refilling of the toes in the same way you
check the fingers

Check for pitting edema by pressing the thumb for at least

15 sec against the shaft of the tibia

Feel the peripheral pulses

Popliteal (flex the knee slightly and place the thumbs

of both hands on the knee with the fingers in the fossa
behind and try to feel the pulse) [I only felt the
popliteal pulse once with Prof. Wosornu in surgery,
dont get depressed if you cant feel it]

Posterior tibial (cup your fingers and place them in the

groove behind the medial malleolus)

Dorsalis pedis (find a prominence on the dorsum of

the foot along the line of the big toe and just distal to it
you will feel the pulse. Don't forget that its anatomical
landmark is between the 1st and the 2nd metatarsal
bones)

Check for swelling of the lower limb

Using the measuring tape, measure 10 or 15 cm from

the patella downward and put your finger on that point

Then wrap the measuring tape around the leg at the

point where your finger is and read the measurement

Repeat the process with the other leg

Then repeat the same thing but this time instead of

measuring downwards go upwards to the thigh

A difference greater than 1 cm between the two legs

is significant

Cardiovascular System
Read the history from Dr_Kindys notes you will find that they are enough
Physical examination
o
Position: at 45
o
General:
1. middle-aged male, lying comfortably
2. well-nourished or cachectic malignancy
severe cardiac failure
(enlarged liver, anorexia,
mesenteric vessels)
3. well-developed

21

conscious
ill-looking
not in distress (resp. distress dyspnea)
7. obviously pale anemia (prosthetic heart vavle hemolytic)
shock
fainting
8. cyanosis central (congenital heart disease with right to left
shunt)
peripheral: reduced cardiac output as in heart
failure, or arterial obstruction
9. jaundice severe congestive cardiac failure
hepatic congestion
prosthetic heart valve inducing hemolysis
10. features of syndromes Marfans
Downs
Turners
11. others connected to IV line or wearing face mask or eye
glasses
Vital signs
1. temperature
2. pulse
3. blood pressure (sitting vs. standing)
4. respiratory rate (tachypnea, dyspnea)
Hands

Warm and moist

Cyanosed, jaundiced, or pale

No muscle wasting or nicotine staining

Janeway lesions & Oslers nodules (infective endocarditis)

[look for them on the pulps of the fingers and the thenar &
hypothenar eminences]

Choiloychia, leukonychia

Splinter hemorrhage trauma

infective endocarditis
rheumatoid arthritis
polyarteritis nodusa

Clubbing cyanotic congenital heart disease

infective endocarditis
unilateral (bronchial AV aneurysm, axillary
artery aneurysm)

Tendon xanthomata type II hyperlipidemia

Palmer xanthomata & tubeo-eruptive xanthoma type III

hyperlipidemia

Flapping tremor heart failure

4.
5.
6.

22

Arterial Pulse

Rate

Rhythm
Regularity Bradycardia
Regular
Physiological (athletes, sleep...)
Drugs (digoxin, B-blockers...)
Hypothyroidism
Hypothermia
Severe jaundice
Increased intracranial pressure
3rd degree AV block + 2nd degree AV
block
Myocardial infarction
o

Irregular

Regular

Sinus arrhythmia (normal slowing of

pulse with respiration)

Wenckebach phenomenon
Irregular

Atrial fibrillation

Multiple supraventricular or
ventricular ectopic beats (frequent
extrasystoles)
Apparent

Pulse deficit atrial fibrillation

ventricular bigemin

Tachycardia
Hyperdynamic circulation

Exercise or anxiety

Fever

Pregnancy

Thyrotoxicosis

AV fistula

Beri beri
Congestive heart failure
Constrictive pericarditis
Drugs (B-agonists,
salbutamol, atropine)
Hypovolemic shock
Supraventricular
tachycardia
Atrial flutter with regular
2:1 AV block
Ventricular tachycardia
Atrial fibrillation

Myocardial ischemia

Mitral valve disease

Thyrotoxicosis

Hypertensive heart
disease

Sick sinus syndrome

Pulmonary embolism

Myocarditis

Acute hyperpyrexia
Multifocal atrial
tachycardia
Atrial flutter with variable
block

Radial synchronization arterial occlusion by atreosclerotic

plaque or aneurysm
arterial occlusion by embolus
aortic dissection
Radiofemoral delay coarctation of aorta leads to upper limb
hypertension
Cardiac pulse
Vessel wall palpable (atherosclerosis)
Volume reflects left ventricular stroke volume

23

Character pulsus alternans (left ventricular failure)

collapsing pulse (aortic incompetence)
(patient with collapsing pulse will most likely
have wide pulse pressure [systolic diastolic]
> 60 or 40 {Im not sure of the number exactly})
Other palpable vessels carotid
brachial (medial to biceps tendon)
femoral
popliteal
dorsalis pedis
posterior tibial
Blood pressure
Auscultatory gap (in healthy people)
Systolic pressure varies between the arms by up to 10 mmHg
In legs blood pressure is higher
During inspiration the systolic and diastolic pressures decrease
by up to 10 mmHg
Pulsus paradoxus is an exaggerated reduction of systolic &
diastolic during inspiration (> 10 mmHg)
constrictive pericarditis
pericardial effusion
acute asthma (severe)
High blood pressure > 140-145/90 mmHg
Malignant blood pressure > 130 mmHg + papilloedema
Postural hypotension fall of > 10 mmHg on standing or > 15
mmHg systolic
Causes hypovolemia
drugs (vasodilation, diuretics...)
Addisson disease
hypopituritarism
diabetes mellitus
idiopathic
The face

Eyes
Jaundice
Pallor
Stigmata of coronary disease xanthelasma
arcus senalis (or arcus
cornealis)
Stigmata of infective endocarditis petechia
Roths spot (in
retina)

24

Mitral facie (rosy cheecks and bluish tongue) occurs in

severe mitral stenosis
Mouth
Diseased teeth infective endocarditis
Central cyanosis
Mucosal petechia infective endocarditis
High arched palate Marfans syndrome (aortic and
mitral regurgitation)

Neck
Carotid artery pulse character & volume (table in
Nicholas)

JVP
Causes of increase right ventricular failure
tricuspid stenosis or regurge
pericardial effusion or constrictive
pericarditis
SVC obstruction
fluid overload
hyperdynamic circulation
Difference between JV & carotid
JVP more seen than felt
pressure at the base of the neck obliterates JVP
JVP decreases with inspiration
Carotid is medial to strenocleidomastoid while JVP is
lateral
JVP is more prominent on lying down
JVP is wavy while carotid is pulsatile
very high JVP causes pulsatile displacement of the ear
lobes
hepatojugular reflex increases JVP (if you press on the
liver the JVP shoots up)

Thyroid enlargement
Praecordium

Inspection
Scar lateral thoracotomy scar (closed mitral
valvotomy)
median sternotomy scar (valve replacement,
coronary artery bypass grafting
Skeletal chest deformities pectus excavatum (funnel
chest): Marfans (alter position of apex beat)
kyphoscolyosis (Marfans)
bulging

25

Pacemaker box obvious pulsation under right or left

pectoral muscle
Visible apex beat
Other visible pulsations pulmonary area (severe
pulmonary hypertension)
aortic area (aneurysm of arch
of aorta or ascending aorta)
epigastric (right ventricular
enlargement, hepatic congestion
due to heart failure, aortic
pulsations, or transmitted pulse)
left parasternal
neck (suprasternal or
supraclavicular)
Palpation
Apex beat
o
Location
normally in the left 5th intercostal space slightly
medial to the midclavicular line
displaced laterally: ventricular enlargement, large
pleural effusion, pneumothorax, scoliosis, pectus
excavatum)
o
Character
hyperkinetic (diffuse): aortic or mitral incompetence,
patent ductus arteriosus, ventricular septal defect
sustained (localized, not shifted): left ventricular
hypertrophy (aortic stenosis, systemic hypertension,
coarctation of the aorta)
tapping (palpable, accentuated S1, not shifted):
mitral stenosis, tricuspid stenosis)
o
Not palpable apex beat: poor technique, thick chest
wall, emphysema, pericardial effusion, shock,
dextrocardia)
o
Parasternal heave: right ventricular enlargement,
severe left atrial enlargement, sometimes it may be
due to severe mitral regurge)
o
Palpable tap of P2: pulmonary hypertension
o
Thrills (organic murmurs)
apical thrills (left lateral position)
Systolic: mitral incompetence, ventricular
septal defect
Diastolic: mitral stenosis
basal thrills (lean forward in full expiration)

26

Systolic: aortic stenosis, pulmonary stenosis,

pulmonary hypertension
Diastolic: aortic incompetence
* can be non-cardiac: vascular goiter, vascular
mediastinal tumour, AV aneurysm
continuous (upper left sternal edge): patent ductus
arteriosus
Percussion (no need)
Auscultation
Bell (low pitch) S3, S4, mitral stenosis, tricuspid
stenosis
Diaphragm S1, S2, click, snap, aortic incompetence,
mitral incompetence
Normal heart sounds
S1 variable (atrial fibrillation, atrial flutter)
loud (mitral stenosis, tricuspid stenosis,
tachycardia or short AV conduction time [e.g. anemia,
hypertension, anxiety, exercise])
soft (prolonged diastolic filling time [1st degree
heart block], delayed onset of left ventricular systole
[left bundle branch block], mitral regurge)
S2 loud aortic component (systolic hypertension,
congenital aortic stenosis)
soft A2 (calcified aortic valve, aortic regurge)
loud P2 (pulmonary hypertension)
splitting
o Increased normal splitting (wider on inspiration)
right bundle branch block, pulmonary
stenosis, ventricular septal defect, mitral
regurge
o Fixed split (wide with no respiratory variation)
atrial septal defect, right ventricular failure
o Reversed split (in expiration) left bundle
branch block, severe aortic stenosis,
coarctation of the aorta, patent ductus
arteriosus
Extra heart sounds
S3 (mid-diastolic)
Left ventricular S3 (louder in expiration, left lateral
position, heard after S2) heard in healthy young
people, pregnant women, aortic regurge, mitral
regurge, ventricular septal defect, ischemic heart
disease

27

Right ventricular S3 (left sternal edge, louder on

inspiration) heard in right ventricular failure,
constrictive pericarditis, tricuspid regurge, pericardial
knock
S4 (late diastolic)
Left ventricular S4 (left lateral position, when left
ventricular compliance is reduced) heard in aortic
stenosis, systemic hypertension, acute mitral regurge,
ischemic heart disease, advanced age
Right ventricular S4 (when right ventricular
compliance is reduced) heard in pulmonary stenosis
and pulmonary hypertension
summation gallop heard when there is rapid heart rate
causing superimposed S3 & S4
Added sounds
opening snap
Mitral stenosis
Tricuspid stenosis
systolic ejection click
Congenital aortic stenosis (louder in expiration)
Pulmonary hypertension (louder in inspiration)
non-ejection systolic click
Mitral valve prolapse
Atrial septal defect
pericardial rub (varies with respiration, loudest when
the patient sits up and breathes out)
pericarditis
diastolic pericardial knock
Constrictive pericarditis
metallic sound
Prosthetic heart valve
Murmurs (read Dr. Akhtars note, it is more than enough;
but here are some of the important ones you should
know)
Mitral stenosis
loud S1
loud P2
opening snap
low pitched rumbling diastolic murmur
late diastolic accentuation may occur
best heard in the left lateral position
accentuated by exercise
Mitral regurge
soft or absent S1
left ventricular S3
pansystolic murmur

28

maximal at the apex

radiating towards the axilla
accentuated by exercise and hand grip
Aortic stenosis
reversed S2
harsh mid-diastolic ejection murmur
ejection click
maximal over the aortic area
extending over the carotid arteries
loudest with the patient sitting up and in full
expiration
accentuated with exercise
Aortic regurge
soft A2
de-crescendo high pitched diastolic murmur
Loudest at the third & fourth left intercostal space
Tricuspid stenosis
diastolic murmur
accentuated by inspiration
loud S1
loud P2
opening snap
low pitched rumbling diastolic murmur
Tricuspid regurge
pansystolic murmur
maximal at the lower end of the sternum
increases on inspiration
Pulmonary stenosis
ejection click
harsh loud ejection systolic murmur
heard best in pulmonary area
accentuated by inspiration
S4 may be present
Pulmonary regurge
decrescendo diastolic murmur
high-pitched
audible at the left sternal edge
increases on inspiration

The back

Lung bases

Signs of heart failure

Late or pan-inspiratory crepitation
Pleural effusion

Pitting sacral edema severe right heart failure

The abdomen

Enlarged tender liver congestion or right heart failure

29

Pulsatile liver tricuspid regurge

Ascites severe right or congestive heart failure
Splenomegaly infective endocarditis
Lower limb

Edema

Pitting edema
Cardiac congestive heart failure, constrictive
pericarditis
Hepatic cirrhosis
Renal nephrotic syndrome
Gastrointestinal malabsorption, starvation

Pitting unilateral edema

DVT
Compression of large veins by tumor or lymph node

Non-pitting lower limb edema

Hypothyroidism
Lymphedema
infections (filariasis)
malignant (tumor lymphatics)
congenital (lymphatic development arrest)
allergy
Peripheral vascular disease
Reduced or absent pulses
Femoral systolic bruits
Marked leg pallor
Absence of hair
Cool skin
Reduced capillary return
Confirm peripheral vascular disease by buergers test
Achilles tendon xanthomata hyperlipidemia
Cyanosis & clubbing of toes without the involvement of
fingers in patent ductus arteriosis
DVT
Calf pain
Swelling of calf and leg
Dilated superficial vein
Increase warmth
Tenderness
Homans sign
Pain in calf when the foot is dorsiflexed
Of little diagnostic value
Can be dangerous because it can dislodge the
thrombus leading to an embolus (pulmonary
embolism)
Causes

30

cardiac failure
prolonged immobilization
trauma
occult neoplasm
DIC
Contraceptive pill
pregnancy
Acute arterial occlusion
Results from
Embolism from thrombus of the heart secondary to
MI
dilated cardiomyopathy
atrial fibrillation
infective endocarditis
Sign of embolus in major artery
pain
pulseless
pale
paralyzed limb
Varicose veins
Inspection
Tortuous dilated branches of long saphenous in front
of the whole leg
Back of lower leg for branches of short saphenous
veins
Signs of venous stasis
inflamed
swollen
pigmented
Palpation
Hard leg veins thrombosis
Tenderness thrombophlebitis
Cough impulse test
Fluid thrill saphenofemoral valve is incompetent
Trendelenburg test
Pethes test
Leg ulcer
Venous stasis ulcer
around maleoli
associated with pigmentation & stasis eczema
Ischemic ulcer
large artery disease (atherosclerosis, on the lateral
side, and the pulses are absent)
small vessels disease (palpable purpura,
leucocytoclastic vasculitis)
Malignant ulcer
31

 basal cell carcinoma

squamous cell carcinoma
melanoma
lymphoma
kaposis sarcoma
Infection
staph aureus
syphilitic gumma
TB
atypical mycobact
fungal
Neuropathic
painless penetrating ulcer on sole of foot due to
peripheral neuropathy (DM, tabes, leprosy)
Underlying systemic disease
DM
pyoderma gangrenosum
Rh arthritis
lymphoma
hemolytic anemia (small ulcer over maleoli e.g.
sickle cell anemia)
Respiratory System

Read the history from Dr_Kindys notes

Physical Examination
o
Position undressed to the waist
o
General

Middle-aged, lying comfortably

Well-nourished, weight loss

TB
carcinoma
chronic bronchitis
emphysema

Well-developed
kyphoscoliosis
bronchiectasis

Not under distress, or under respiratory distress

tracheal descent
tachypnea
accessory muscles of respiration

Conscious, or confusion or coma

hypoxia
hypercapnea

Obviously pale
anemia due to chronic hemoptysis

Cyanosed
32

Central (tongue)
o
COPD
o
Lung diffusion defect (pneumonia)
o
Pulmonary AV fistula
o
Massive pulmonary embolism

Peripheral
o
Causes of central cyanosis
o
SVC syndrome
Jaundice cor pulmonale
Observe the symptoms
Cough
o
Lack of explosive sound (hollow, bovine sound)
vocal cord paralysis
o
Muffled, wheezy airflow limitation
o
Loose productive chronic bronchitis,
bronchiectasis, pneumonia
o
Dry, irritating chest infection, asthma, carcinoma of
the bronchus, left ventricular failure, interstitial lung
disease, ACE inhibitors
Sputum
o
Purulent
o
Mucoid
o
Mucopurulent
o
With blood
Stridor (croaking noise, loud on inspiration)
o
Sudden onset
anaphylaxis
toxic gas inhalation
acute epiglotitis
inhaled foreign body
o
Gradual onset
laryngeal or pharyngeal tumor
crico-arteroid rheumatoid arthritis
bilateral cord palsy
tracheal carcinoma
paratracheal compression by lymph nodes
post tracheostomy
Hoarseness
o
Laryngitis
o
Recurrent laryngeal nerve palsy associated with lung
carcinoma
o
Laryngeal carcinoma
Others
o
Connected to IV line or face mask
o
Fetor of breath suppurative lung syndrome

33

Cushingoid features
steroid use in asthma or chronic bronchitis
ectopic ACTH secretion by bronchogenic (small
cell) carcinoma

Vital sign
o
Temperature any acute or chronic chest infection
o
Pulse

Tachycardia
hypoxia
hypercapnia
cor pulmonale

Collapsing pulse
hypercapnia

Tachycardia & pulsus paradoxus

severe asthma
o
Blood pressure
o
Respiratory rate

Tachypnea ( > 14-16/min)

sign of dyspnea
Hands
o
Warm & moist hypoxia & hypercapnia
o
Cyanosed, jaundiced, & pale
o
Wasting & weakness of small muscle of hand infiltration of C8 &
T1 nerve root by lung tumor
o
Palmer erythema

CO2 retention

Respiratory failure

COPD

Lung carcinoma
o
Nicotine staining
o
Nail

Pallor anemia

Koilonychia iron deficiency anemia

Leukonychia hypoalbuminemia

Clubbing
HPO (primary lung carcinoma, pleural mesothelioma)
bronchogenic carcinoma
bronchiectasis
lung abscess & empyema
pulmonary fibrosis
fibrosing alveolitis
TB (uncommon)
*chronic bronchitis & emphysema do NOT cause clubbing
o
Flapping tremor severe CO2 with respiratory failure (severe
chronic airflow limitation)

34

Eye

Joints

o
o
o

Anemia
Jaundice
Horners syndrome

Apical lung tumor (compress sympathetic nerve in the neck)

o
Loss of sweating
o
Constricted pupil
o
Partial ptosis

Sinuses
o

Its tenderness sinusitis

Mouth
Reddened pharynx & enlarged tonsils URTI
Tongue central cyanosis
Broken or rotten tooth predispose to
lung abscess
pneumonia
Facial plethora or cyanosis SVC obstruction
Neck
o
Inspection

Scars
lymph node biopsy
TB lymphadenitis

Sinuses
TB
o
Lymph node
o
Tracheal displacement

Slight displacement to the right is normal

Toward lesion
o
upper lobe collapse
o
upper lobe fibrosis
o
pneumonectomy

Away from affected side

o
Massive pleural effusion
o
Tension pneumothorax
o
Tracheal tug gross over-expansion of chest with airflow
obstruction
o
JVP cor pulmonale (increases JVP)
*we complete general examination by looking for lower limb edema &
cyanosis in feet
Chest
o
Inspection

Localized asymmetry
o
Localized flattening
pleural pathology
o
o
o

35

lung pathology
o
Bulging
neoplastic lesion
aneurysm
cardiac enlargement
Shape of chest
o
Barrel chest

Severe asthma

Emphysema

Thoracic kyphosis
o
Pigeon chest

Chronic childhood regular illness

Rickets
o
Funnel chest

Developmental defect

Leads to
Compression of the heart
Apex beat displacement
Restrictive ventilatory defect
o
Harrisons sulcus (linear depression at lower ribs just
above the costal margin at the site of attachment of the
diaphragm)

Chronic asthma in childhood

Rickets
o
Kyphoscoliosis

May be
Idiopathic (80%)
Secondary to poliomyelitis
Associated with Marfans syndrome

It causes
Increased antero-posterior diameter
Displaced apex beat & trachea
Restrictive ventilatory defect
Heart failure
Lesion of chest wall
o
Scars
surgical operation
surgical drainage
o
Radiotherapy
erythema & thickening
indicates lung carcinoma or lymphoma
o
Subcutaneous emphysema (crackling sensation on
palpation)
pneumothorax
ruptured esophagus

36

air in the mediastinum

o
Prominent veins
SVC obstruction
o
Breast
gynecomastia indicates bronchogenic carcinoma

Movement of chest wall

o
Assess asymmetry of chest expansion by inspection
o
Decreased unilaterally
local pulmonary fibrosis
consolidation
collapse
pleural effusion
pneumothorax
o
Decreased bilaterally
COPD
diffuse pulmonary fibrosis
asthma
emphysema
Palpation

Plapate for
o
Cutaneous or subcutaneous masses
o
Subcutaneous emphysema
o
Tenderness
rib fracture
tumor invade chest wall

Apex beat
o
Displaced toward side of lesion
collapse of lower lobe
localized pulmonary fibrosis
o
Away from side of lesion
pleural effusion
tension pneumothorax
o
Impalpable
hyperexpanded chest secondary to airflow limitation

Chest expansion

Measuring maximum chest expansion

o
5 cm is normal
o
1-2 cm is abnormal

Tactile fremitus
o
DDx of decreased TVF

Thick skin & musculature

Thick pleura

Pleural effusion

Pneumothorax

Fibrosis

Emphysema
37

Massive pulmonary edema

Bronchial obstruction
o
DDx of increased TVF

Consolidation

Lung collapse in intimate contact with trachea or

bronchi

Lung mass

Heavy but not obstructive pulmonary secretions

Percussion
Resonance
o
Normal lung
Hyperresonance
o
Pneumothorax
o
Acute attack of bronchial asthma
o
Emphysema
o
Cavity (TB cavity, neoplastic cavity, lung abscess)
Dullness
o
Consolidation
o
Collapse
o
Fibrosis
o
Pleural thickening
Stony dullness
o
Pleural effusion
o
Empyema
o
Hemothorax
o
Chylothorax
o
Pneumonectomy
o
Lobectomy
Cardiac dullness
o
Decreased emphysema or asthma
o
Increased pericardial effusion
Auscultation
Quality of breath sounds (bell over clavicles lung apices;
diaphragm over other areas)
o
Vesicular

Normal
longer inspiration
expiration only audible early & shorter
no gap

Abnormal (in airway obstruction)

prolonged expiration
both phases equal
no gap
o
Bronchial

Abnormal

38

equal phases
louder expiration
gap
occurs in
Lung consolidation
Local pulmonary fibrosis
Pleural effusion
Collapsed lung
Intensity of breath sounds
o
Decreased

COPD

Pleural effusion

Pneumothorax

Pneumonia (consolidation)

Large neoplasm

Pulmonary collapse

Pulmonary fibrosis
Added sounds
o
Rhonchi (continuous wheeze)

Louder in expiration

Inspiratory wheeze severe airway narrowing

High pitch small airway

Low pitch large airway

Heard in
Bronchial asthma (high pitch)
Chronic bronchitis (low pitch)
Emphysema
Carcinoma of lung
localized, single quality rhonchi
not clear with cough, louder in inspiration
o
Crepitation (intermittent)

Early inspiratory
Medium coarse
COPD (chronic bronchitis, emphysema)
asthma
carcinoma (localized rhonchi)

Late or pan-inspiratory
Fine
pulmonary fibrosis
Medium coarse
left ventricular failure
Coarse
bronchiectasis (gurgling, changes with cough)
o
Pleural friction rub

39

Continuous or intermittent grating noise, louder with

deep inspiration

Pleurisy pneumonia
Vocal resonance

Heart
Increased JVP
Increased P2
Louder P2 pulmonary hypertension
Cor pulmonale due to
COPD
pulmonary fibrosis
pulmonary thromboembolism
severe kyphoscoliosis
Abdomen
o
Liver ptosis
COPD
o
Hepatomegaly
secondary to deposit of lung carcinoma
o
Ascites
cor pulmonale
Others
o
Pembertons sign
SVC obstruction
facial plethora
inspiratory stridor
non-pulsatile elevation of JVP
o
Feet
Edema & cyanosis cor pulmonale
Evidence of DVT
Causes of consolidation
o
Lobar pneumonia (90% pneumococcus)
o
Bronchial pneumonia (bacterial, viral: influenza, adenovirus,
measles, cytomegalovirus)
o
Primary atypical pneumonia (mycolpasma pneumonia)
Causes of collapse
o
Intraluminal (mucus asthma, cystic fibrosis)
o
Mural (bronchial carcinoma)
o
Extramural (peribronchial lymphadenopathy, aortic aneurysm)
Causes of pleural effusion
o
Transudate

Heart failure

Hypoalbuminemia (nephrotic syndrome, chronic liver

disease)

Hypothyroidism

Meigs syndrome
o
o
o
o

40

Exduate

Pneumonia

Neoplasm

TB

Pulmonary infarction

Subphrenic abscess

Acute pancreatitis

Connective tissue disease (SLE, Rh arthritis)

Drugs (cytotoxin)

Irradiation

Trauma
o
Hemothorax

Severe trauma to the chest

Rupture of pleural effusion containing blood vessel

o
Chylothorax

Surgery or trauma to thoracic duct

Carcinoma or lymphoma of thoracic duct

o
Empyema

Pneumonia

Lung abscess

Bronchiectasis

TB

Penetrating chest wound

Causes of pneumothorax
o
Spontaneous

Sub-pleural bullae rupture

Emphysema with rupture of bullae

o
Traumatic

Rib fracture

Penetrating chest wall injury

During pleural aspiration

Causes of tension pneumothorax
o
Trauma
o
Mechanical ventilation at high pressure
Causes of generalized emphysema
o
Emphysema associated with chronic bronchitis & smoking
o
Idiopathic
o
Alpha-antitrypsin deficiency
Causes of chronic bronchitis
o
Smoking
o
Recent chest infection
Causes cystic fibrosis
o
Upper lobe (SCHART)

Silicosis

Sarcoidosis
o

41

Coal workers pneumoconiosis

Histocytosis
Ankylosing spondylitis
Allergic aspergillosis
Radiation
TB
Lower lobe (RASIO)

RA

Asbestosis

Scleroderma

Idiopathic fibrosing alveolitis

Other: drugs (busulphan, methotrexate)

Gastrointestinal Tract
Read the history from Dr_Kindys notes
o Pain radiation
To the back
Pancreatitis
Perforating peptic ulcer
To the shoulders
Diaphragmatic irritation
To the neck
Reflex esophagitis
Physical examination
o Position & exposure (from nipple to mid-thigh lying flat with the arms by the
side)
o General
Young male, lying comfortably on bed
Not in distress
Well-nourished
With anorexia
Malignancy
Malabsorption
Hypermetabolic state (thyrotoxicosis)
Dysphagia
Well-developed
Sickle cell disease
Thalassemia
Glycogen storage disease
Conscious, comatose, or stuperous
Hepatic encephalopathy
Decompensated advanced cirrhosis (chronic liver failure)
Fulminant hepatitis (acute liver failure)
Results from

42

Liver cell damage unable to remove toxins (amonia,

mercaptans, short chain fatty acids, amines)
portosystemic shunting
Obviously pale
Iron deficiency anemia
Malabsorption
Blood loss
Megaloblastic anemia
Malabsorption
Hemolytic anemia
Hypersplenism
Anemia of chronic illness
Jaundiced (natural daylight DONT FORGET)
Hemolytic jaundice
Pale lemon yellow color
Dark stool
Normal urine
Non-hemolytic unconjugated jaundice
Gilbert disease
Criggler- Najjar syndrome
Hepatocellular
Hepatitis
Cirrhosis
Drugs
Paracetamol overdose
Anti-TB
o Isoniazid
o Rifampicin
o Pyrazinamide
Statins
Sodium valproate
Monoamine oxidase inhibitors
Halothane
Antibiotics
o Flucloxacillin
o Fusidic acid
o Co-amoxiclav
o Nitrofurantoin
o Anabolic steroids
o Oral contraceptives
o Chlorpromazine
o Prochlorperazine
o Sulfonylureas
o Gold
Cyanosed
o

43

Severe long standing chronic liver disease

Skin
Pigmentation
General skin pigmentation
Liver cirrhosis
Hemochromatosis
Addison type pigmentation (due to malabsorption)
Nipples
Palmer creases
Pressure areas
Mouth
Peuts- Jeghers syndrome
Freckle- like spots on lips & buccal mucosa & big toes
Associated with
Hamartoma of SI (50%)
Hamartoma of colon (30%)
Present with
Intussception
Bleeding
GI carcinoma
Acanthosis Nigricans
Black velvety color of epidermis
Can be in axilla or body folds like genital areas
Associated with
GI carcinoma
Lymphoma
Diabetes mellitus
Acromegaly
Hereditary hemorrhagic telangectasia (Rendu- Osler- Weber
syndrome)
Multiple small telangectasia in lips, tongue, & skin
Associated with
AV malformation in liver
Patient presents with
GI bleeding
Pophyria Cutanea Tarda
Vesicles in exposed areas of skin & hand with scarring
Disorder of porphoryn metabolism dark urine
Associated with
Alcoholism
Liver disease
Hepatitis C
Systemic sclerosis
Tense tethering of skin (hardening & thickening)
Associated with

44

Gastro-esophageal reflux
Esophageal motility disorders
GI motility disorders
Dermatitis herpetiformis
Pruritic vesicles on knees, elbows, & buttocks
Associated with
Celiac disease
Others
Connected to IV line
o Vital sign
Temperature
GI infection
Food poisoning
Pulse
Blood pressure
Respiratory rate
o Hand
Nails
Koilonychia
Iron deficiency anemia
Bleeding
Malnutrition
Leukonychia
Hypoalbuminemia
Renal failure
Lymphoma
Fungal infection
Congenital
Muerke lines
Baeus line
Terrys nails
Clubbing
Cirrhosis
Irritable bowel disease
Malabsorption syndrome
Cystic fibrosis
Celiac disease
Thyrotoxicosis
Pale nail beds
Cyanosis
Wasting of small muscles of hand (alcoholism)
Temperature & moisture (warm & moist)
Hyperthyroidism
Palmer creases for pallor & pigment (jaundice)
Palmer erythema

45

Liver cirrhosis
Pregnancy
Oral contraceptives
Thyrotoxicosis
Rheumatoid arthritis
Polycythemia
Dupuytrens contractures
Manual worker
Alcoholic cirrhosis
Familial
Thickening & contracture of the palmer fascia causing permanent
flexion (mainly ring finger)
Tremors
Coarse
Wilsons disease
Alcoholism
Flapping (Asterixis)
Hepatic failure
Heart failure
Respiratory failure
Renal failure
Hypoglycemia
Barbiturate intoxication
Decreased potassium, magnesium
Absent at rest
Absent when coma develops
o The arms
Bruising ecchymosis (large bruise)
Hepatocellular damage & impaired synthesis of clotting factors (II,
VII, IX, X)
Impaired absorption of vitamin K in obstructive jaundice so impaired
synthesis of clotting factors
Petechia
Chronic alcoholism
Bone depression thrombocytopenia
Hypersplenism secondary pulmonary hypertension
thrombocytopenia
Acute hepatic necrosis dissiminated intravascular coagulation
Muscular wasting & proximal myopathy
Malnutrition in alcoholics
Scratch marks
Obstructive jaundice
Primary biliary cirrhosis
Spider nevi

46

Arms, neck, chest wall, occasionally may bleed blanching with

pressure on central arteriole
Caused by
Liver cirrhosis
Transiently with viral hepatitis
Pregnancy
Axillary Lymphadenopathy (5 groups of lymph nodes)
Loss of axillary hair (sparse)
Campbell de Morgan
Venous stars (increase venous pressure)
o Face
Eyes
Jaundice
Pallor
Kayser- Fleischer rings
Brownish green rings
Seen in
Wilsons disease
Cirrhosis
Other cholestatic liver disease
Iritis
Inflammatory bowel disease
Xanthelasma
Hyperlipidemia in primary biliary cirrhosis
Black eye sign
Peri-orbital purpura following sigmoidoscopy in amyloidosis
Parotid gland
Bilateral enlargement
Mixed parotid tumor
Mumps
Sarcoidosis
Lymphoma
Alcohol associated parotitis
Malnutrition
Severe dehydration
Unilateral enlargement
Salivary calculus
Tumor infiltration
Mouth
Angular stomatitis
Vitamin B6 deficiency
Vitamin B12 deficiency
Iron deficiency
Folate deficiency
Teeth
False teeth

47

Ulcer
Gum hypertrophy
Phenytoin
Pregnancy
Scurvy
Gingivitis
Leukemia
Pigmentation
Heavy metals
Drugs (antimalarials, oral contraceptives)
Addisons disease
Peutz- Jeghers syndrome
Malignant melanoma
Decayed
Fetor
Breath
Faulty oral hygiene
Fetor hepaticus (sweet, methyl mercaptans)
Severe hepatic cell disease
Diabetic Ketoacidosis (sickly sweet smell)
Uremia (fish breath)
Alcohol
Putrid
Anaerobic chest infection
Cigarettes
Tongue
Macroglossia
Congenital
o Down syndrome
o Acromegaly
Tumor infiltrate
o Hemangioma
o Lymphangioma
Amyloidosis
Glossitis (smooth tongue & erythematous)
Iron deficiency anemia
Vitamin B12 deficiency
Folate deficiency
Leukoplakia (S)
Smoking
Sore teeth
Sepsis
Syphilis
Spirits
No apparent cause

48

Geographic tongue
Vitamin B12 deficiency
Lingua nigra
Increase keratin bismuth
Mouth ulcers
Common
Aphthous
Drugs (gold, steroid)
Trauma
Uncommon
GI
o Crohns disease
o Ulcerative colitis
o Celiac disease
Rheumatoid
o Behkets syndrome
o Reitre syndrome
Erythema multiforme
Infection
o Viral (herpes zoster, herpes simplex)
o Bacterial (syphilis, TB)
Self-inflicted
HIV
Candidiasis (thrush)
Immunocompromised
Person on broad spectrum antibiotics (kills normal flora)
Neck
Cervical Lymphadenopathy (left supraclavicular virchows node)
Troisier sign
Combination of virchows node & carcinoma of stomach
Chest
Spider nevi
Hair on chest
Muscle wasting & fasiculations
Gynecomastia
Cirrhosis
Alcoholic cirrhosis
Chronic obstructive hepatitis
Drugs
Digoxin
Cimitidine
Alcoholism without liver disease (damage of leydig cells of testis)
Abdomen
Inspection
From foot of bed

49

General abdomen distension

o Fluid
o Fat
o Fetus
o Feces
o Flatus
o Tumor
Sunken or scaphoid abdomen
o Starvation
o Wasting
Asymmetry
o Enlarged organ
o Abdominal tumor
o Pelvic tumor
Midline structure
Substernal angle (wide)
o Pregnancy
o Organomegaly
o Ascites
o Abdominal tumor
Umbilicus
o Normally inverted, midway between xiphysternum and
symphysis pubis
o Flat & everted abdominal distension
o Pushed upwards pregnancy or tumor
o Pushed downwards hepatomegaly, splenomegaly, upper
abdominal tumor
o Pubic hair loss liver cirrhosis
Movement
With respiration
o Lack of part or whole movement peritonitis
o Unequal movement phrenic nerve palsy
Epigastric pulsation
o Abdominal aortic aneurysm
o Tricuspid regurge (hepatic)
o Right ventricular enlargement
o Normal in thin
Visible peristalsis (upper abdomen from left to right)
o Pyloric stenosis (peptic ulcer or tumor)
o Small intestine obstruction (center of abdomen)
o Large intestine obstruction (in upper abdomen)
Abdominal wall
Scars
o Operation

50

Liver biopsy
Laparoscopy
Iliostomy or colostomy
Prominent veins
o Severe portal hypertension (caput medusa)
o Inferior vena caval obstruction (flow towards the head
Stria
o Ascites
o Pregnancy
o Recent loss of weight
o Wide, purple Cushing syndrome
Skin lesion
o Vesicles of herpes zoster
o Sister Joseph nodules deposits of metastatic tumor in the
umbilicus
o Umbilical black eye (Cullen sign) extensive hemorrhagic
peritonitis or acute pancreatitis
o Skin discoloration in flanks (Grey-Turner sign) severe
acute pancreatitis
Bruises & hemorrhages
Cautery mark
Superficial masses
Inguinal orfices
Palpation
Superficial
Abdomen is soft & lax guarding & rigidity peritonitis
No area of tenderness which can be (appendicitis,
cholecystitis, peritonitis, nerveousness)
No area of rebound tenderness peritonitis
No palpable superficial mass
Deep palpation
No palpable deep masses
Organ palpation
Liver
Gallbladder
Spleen
Kidney
Pancreas
Aorta
Bowel
Bladder
Inguinal lymph nodes
Testes
Anterior abdominal wall
o
o
o

51

Abdominal tumor

Liver
o The liver is palpable 4 cm below the costal margin, upper border is at the
level of the 6th rib in the mid-clavicular line
o Firm in consistency
o Smooth surface
o Regular sharp edge
o Not tender
o Not pulsatile
o Moves with respiration
o Normal liver span 8-12 cm
o Hepatomegaly
Massive
Metastasis
Alcoholic liver disease with fat infiltration
Myeloproliferative disease
Right heart failure
Hepatocellular carcinoma
Moderate
The above causes
Hemochromatosis
Chronic leukemia & lymphoma
Fatty liver secondary to diabetes mellitus
Infiltrates e.g. amyloid
Mild
The above causes
Hepatitis
Biliary obstruction
Hydatid disease
HIV infiltration
o Small liver
Advanced cirrhosis
Rapidly with acute hepatic necrosis
o Firm & irregular liver
Cirrhosis
Hepatoma
Metastasis
Hydatid disease
Granulomatous infiltration
o Tender liver
Infection (hepatitis)
Hepatoma
Hepatocellular carcinoma
Right heart failure (congestion)
52

Budd-Chiari syndrome (congestion)

Hepatic abscess
Pulsatile liver
Tricuspid regurge
Hepatoma with hepatocellular carcinoma
Vascular abnormality
Soft smooth tender liver
Hepatitis
Congested liver
Budd-Chiari syndrome
Right heart failure
Hard & irregular
Metastasis
Macronodular cirrhosis
DDx of normal span, palpable liver
Ptosis
Asthma
Emphysema
Subdiaphragmatic collection
Riedels lobe

Gallbladder
o Palpable below the right costal margin as it crosses the lateral border of the
rectus abdominus muscle
o A palpable gallbladder will be bulbous, focal rounded soft mass that moves
with inspiration (downwards)
o Causes of enlargement
With jaundice
Carcinoma of the head of the pancreas
Carcinoma of the ampulla of vater
Without jaundice
Mucocele or empyema of gallbladder
Carcinoma of gallbladder (stone hard irregular surface)
Acute cholecystitis
o Courvoisiers law
If the gallbladder is enlarged and the patient is jaundiced, the cause is
less likely to be gallstones, rather a carcinoma of the pancreas or lower
biliary tree resulting in obstructive jaundice is likely to be present
A gallbladder with stones is usually fibrosed, not capable of enlargement
o Murphys sign (the patient catches his breath during inspiration while you
palpate the gallbladder) if cholecystitis is suspected
o 50% of enlarged gallbladders are NOT palpable

Spleen
o Spleenomegaly
53

Massive
Chronic myeloid leukemia
Myelofibrosis
Malaria
Kala Azar
Primary lymphoma of spleen
Tropical spleenomegaly
Moderate
The above causes
Portal hypertension
Lymphoma
Leukemia (acute or chronic)
Thalassemia
Storage disease e.g. Gauchers disease
Mild
The above causes
Other myeloproliferative disorders
Polycythemia rubra vera
Essential thrombocythemia
Hemolytic anemia
Magaloblastic (rarely)
Infection
Viral
Infectious mononucleosis
Hepatitis
Bacterial
Infectious endocarditis
Protozoal
Malaria
Connective tissue disease
Rheumatoid arthritis
SLE
Polyarteritis nodosa
Infiltration
Amyloid
Sarcoid
o Spleenomegaly without portal hypertension
Chronic active hepatitis
Primary bleary cirrhosis
Alcoholic hepatitis
Idiopathic hemochromatosis
o Dullness in Traubes area
Spleenomegaly
Enlarged left lobe of the liver
Tumor of fundus of the stomach

54

Massive pleural effusion

Severe cardiomegally
o Hepatospleenomegaly
Hematological
Lymphoma
Leukemia
Pernicious anemia
Sickle cell disease
Infection
Acute viral hepatitis
Infectious mononucleosis
Cytomegalovirus
Infiltration
Amyloid
Sarcoid
Connective tissue disease
SLE
Acromegaly
Thyrotoxicosis
Chronic liver disease with portal hypertension

Pancreas
o Pancreatic pseudocyst after acute pancreatitis
o Rounded swelling above the umbilicus
o Tense
o Does NOT descend with inspiration
o Feels fixed
o Pancreatic carcinoma may be palpable in thin patients

Aorta
o Epigastric pulsation normal in thin patients
o Can be due to aortic aneurysm due to atherosclerosis
o Measure width of pulsation
o Aortic aneurysm EXPANSILE pulsation

Bowel
o Severely constipated patient with hard feces
Palpable sigmoid colon
The mass can be indented
o Rarely carcinoma of bowel is palpable especially cecum, if palpable
doesnt move with respiration

Bladder
o A full bladder may be palpable above the symphysis pubis
o Regular, smooth, firm, oval shaped with no lower border full bladder
55

Percussion > dull

Inguinal lymph nodes

o Along the inguinal ligament
o Along the femoral vessels

Testes
o Testicular atrophy chronic liver disease

Anterior abdominal wall

o Lumps
Lipoma
Sebaceous cysts
Dermal fibroma
Malignant deposit melanoma or carcinoma
Epigastric hernia
Umbilical or para-umbilical hernia
Inguinal hernia
Rectus sheath divarication
Rectus sheath hematoma

Abdominal mass
o Position
o Size
o Consistency
o Shape
o Mobility
Moves down with inspiration
Stomach
Transverse colon
Liver
Spleen
Gallbladder
Kidney
No movement with respiration
Pancreas
Para-aortic lymph nodes
Descending colon
Cecum
Urinary bladder
o Ability to get above the mass
Able to
Enlarged kidney
Pyloric tumor
Not able to
56

Enlarged liver
Enlarged spleen
o Ability to get below the mass
Able to
Colonic mass
Not able to
Urinary bladder
Uterus
Pelvic tumor
o Causes of mass in
Right iliac fossa
Appendicular abscess
Carcinoma of the cecum
Crohns disease
Pelvic kidney
Ovarian tumor or cyst
Carcinoid tumor
Amebiasis
Psoas abscess
Iliocecal TB
Hernia
Left iliac fossa
Feces
Carcinoma of sigmoid or descending colon
Diverticular abscess
Ovarian tumor or cyst
Psoas abscess
Hernia
Upper abdomen
Retroperitoneal Lymphadenopathy
Lymphoma
Teratoma
Abdominal aortic aneurysm
Carcinoma of the stomach
Pancreatic pseudocyst or tumor
Gastric dilatation
Pyloric stenosis
Acute dilatation in diabetic Ketoacidosis
After surgery
Carcinoma of the transverse colon
Pelvis
Bladder
Ovarian tumor or cyst
Uterus
Pregnancy

57

Tumor
Fibroids

Percussion (cont examination of abdomen)

Liver dull
Spleen dull
Kidney resonant
Urinary bladder dull
Ascites
Early sign (accumulation of 2 L)
o Dullness in flanks
Gross ascites
o Abdominal distension
o Everted umbilicus
o Positive shifting dullness (fluid & air in intestinal obstruction
& massive ovarian cyst may cause some confusion)
o Fluid thrill (massive ascites)
o Causes of ascites
o Transudate (< 30 g protein/L fluid)
a. Cirrhosis
b. Congestive heart failure
c. Hypoalbuminamia e.g. nephrotic syndrome
d. Meigs syndrome
o Exudate (> 30 g protein/L fluid)
a. Malignant disease (bowel , gynecological)
b. Infection (TB, pyogenic)
c. Budd- Chiari syndrome
d. IVC obstruction
e. Myxedema
f.
Lymphatic obstruction (Chylous ascites)
Auscultation
Bowel sound (below umbilicaus present or absent)
Normally
o Soft, gurgling character intermitently
Paralytic ileus
o Complete absence of sound over 3 minute period
Bowel obstruction
o Louder, more high pitched with a tinkling quality
Diarrheal
o Gurgling sound audible even without stethoscope
borborygmi
Friction rubs (rough croacking or graiting noise as the patient
breathes inflammation of the peritoneum)
Liver
o Hepatocellular carcinoma
58

Metastasis
Recent liver biopsy
Liver infarct
Liver abscess
Gonococcal perihepatitis
Spleen
o Splenic infarct
Bruits
Arterial systolic bruit over the liver
o Hepatocellular carcinoma
o Acute alcoholic hepatitis
o AV malformation
Over enlarged kidney
o Hypernephroma
Lower abdomen
o Narrowing of aorta or iliac artery
o Aortic aneurysm
Upper abdomen
o Referred from heart
o Narrowing of small mesenteric vessels
Renal bruits
o Renal artery stenosis
Venous hum (increase during inspiration)
Typically heard between xiphysternum & umbilicus portal
hypertension
Cruveilhier- Baumgarten sign
o Association of venous hum at the umbilicus & dilated
abdominal wall veins cirrhosis of the liver
Presence of venous hum or caput medusa suggest that the
site of portal obstruction is intrahepatic rather than in the portal
vein itself
Rectal examination
o
o
o
o
o

Surgery Case Report

Sunday, May 21st, 2006

ID
Mr. Humood is a 24 year old single, Saudi gentleman. He is originally from
Riyadh but lives in Al-Khobar and works as a guard in the King Fahad Bridge.
Chief Complaint
The patient was admitted through the ER on Thursday, May 18 th, 2006
complaining of abdominal pain of about 5 hours duration.
History of Presenting Illness

59

The patient was apparently well until early Thursday morning around 3:30 a.m.
when he was woken from sleep by abdominal pain that was worst around the
umbilicus. The pain started suddenly, was colicky in nature, and severe enough
to wake him from sleep. After a few hours the pain became worse in the right iliac
fossa. It was exacerbated by movement and only relieved by an injection of
analgesics. The pain was associated with pain and a burning sensation on
micturation as well as dark urine. After the pain started, the patient felt nauseous
and anorexic, and vomited three times, but the vomiting didnt relieve the pain.
The patient was constipated for 2 days before the onset of the pain and remained
constipated after its onset. The patient was afebrile, denied having diarrhea,
rigors, hematuria, or discharge with the urine.
An appendectomy was done on Friday, May 19th, 2006 after which the pain
ended and there were no complications after the operation.
Past History
Trauma: none
Blood transfusion: none
Medical: none (not known to have diabetes mellitus, hypertension, asthma, or
other illnesses)
Surgical: none
Drug History
None
Allergies
He is allergic to dust (eye allergy) but no known allergies to foods or drugs.
Family History
His father is alive, aged 75, with hypertension and glaucoma
His mother is alive , aged 51, with rheumatoid arthritis
Siblings
o 1 sister
o 5 brothers
o All alive and apparently well, with no similar conditions

relatives

Travel History
No history of recent travel
Social History
Single gentleman working as a guard in the King Fahad Bridge
Non-smoker
Doesnt drink
Systemic Review
CNS
o No tremors
60

o No headaches
o No sensory nor motor disturbances

Eyes
o No vision disturbances
o No discharge, redness, nor pain

Ears
o No hearing disturbances
o No ringing, discharge, nor bleeding

Nose
o No disturbance in smell
o No discharge nor bleeding

Throat
o No soarness
o No difficulty nor pain in swallowing

CVS
o No palpitations
o No chest pain
o No ankle swelling
o No hypertension
o No history of leg cramps, no claudication
o No history of varicose veins

RS
o No couch, sputum, nor Hemoptysis
o No wheezing nor dyspnea

Musculoskeletal
o No mylagia nor arthralgia
o No stiffness
o No swelling over the joints, erythema, nor tenderness

Hematological & RES

o No known blood diseases
o No spontaneous bleeding nor bruising
o No history of Lymphadenopathy nor hepatosplenomegaly

Skin
o No change in color
o No itching nor rashes

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o No history of cellulites

Endocrine/ Metabolic
o No heat nor cold intolerance
o No change in sweating
o No polydipsia
Monday, May 22nd, 2006

Physical Examination
General
Young male, conscious and alert, sitting comfortably on bed. Well-developed
and well-nourished. Not in pain nor respiratory distress. Not obviously pale,
cyanosed, nor jaundiced.

Vital signs
Temperature: 37.2
Pulse: 80 beats/min
Blood pressure: 130/70 mmHg
Respiratory rate: 20 breaths/min

within normal values

Hands
The pulse is 80 beats/min, regular, equal bilaterally, of normal volume and
character, no palpable vessel wall, and no radiofemoral delay
Nails are not pale nor cyanotic
No koilonychias
No clubbing
No palmer erythema

Head & Neck

o Eyes
No ptosis
No pallor nor jaundice
Normal movement in all directions
o Mouth
No peripheral nor central cyanosis
Normal color of gums, no bleeding
Tonsils not enlarged
o Neck
No palpable lymph nodes
No palpable masses
No thyroid swelling
Trachea in central position

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Chest examination
o Inspection
Symmetrical chest movement
No scars nor deformities
No visible veins
o

Palpation
Normal chest expansion and tactile vocal fremitus
No tenderness, subcutaneous emphysema, nor subcutaneous nodules
No enlarged axillary lymph nodes
Palpable apex beat in 5th intercostal space midaxillary line

o Percussion
Normal resonant note on all parts of the lungs
o Auscultation
Normal air entry
Vesicular breathing equal bilaterally
No added sounds
Normal vocal resonance on all parts of the lungs
Normal S1 + S2
No added sounds

Abdominal examination
o Inspection
Reduced movement with respiration (thoracoabdominal respiration)
5 cm horizontal scar in the right iliac fossa that is not infected
No dilated veins
No visible peristalsis
No visible pulsations
Normal hair distribution
No pigmentation of skin
No swellings
o Palpation
Superficial
No change in temperature
No rigidity
Tenderness and guarding over the right iliac fossa
Tenderness

Deep
Not done (patient refused)
o Percussion
Normal tympanic (wasnt done on the right half of the abdomen as the
patient refused)
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o Auscultation
Normal bowel sounds
No bruits
o Scrotal & Digital Rectal Exam
Not performed

Lower limbs
No edema
No muscle wasting
No change in temperature
Normal sensation
Poplitial, posterior tibial, and dorsalis pedis pulses were present

Problem List
Active
Abdominal pain
Constipation
Dysuria and burning sensation on micturation
Inactive
None
Clinical Impression
The patient had acute appendicitis which was treated with an appendectomy and
had no complications after the operation.
Differential Diagnosis
Acute appendicitis
Acute pyelonephritis
Renal colic
Cystitis
Non-specific mesenteric adenitis
Meckels diverticulitis
Crohns disease
Mesenteric embolus
Right sided colonic diverticulitis
Acute intestinal obstruction
Perforated peptic ulcer
Acute cholecystitis
Pancreatitis

GOOD LUCK!!

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