Short Cases of Medicine

SHORT CASES
OF
MEDICINE
Respiratory system examination
Examination of respiratory system
Inspection
Palpation
Percussion
Auscultation
Inspection
1. Size And Shape Of Chest Wall
2. See Any Asymmetry Present Or not
3. Movement Of The Chest
4. Respiratory Rate And Rhymth , Pattern
5. Evidence of respiratory distress
Intercostals fullness or recession / in drawing
Suprasternal , Supraclavicular excavation
Prominence of accessory respiratory muscle
lip pursing
6. Neck swelling SVO
7. Scar mark, visible impulse and Engorged vein present or not
8. Gynaecomastia and spider nevi and pigmentation
1. SIZE AND SHAPE OF CHEST WALL

The normal chest is bilaterally symmetrical and elliptical in cross-section Cause of pectus carinatum
Then any deformity presents such deformity of sternum, spine and chest wall childhood asthma
osteomalacia and rickets.
Sternum
Pectus carinatum (pigeon chest).
o Sternum and costal cartilages are prominent and protrude
from the chest or forward bulging of the chest .
Pectus excavatum (funnel chest).
o Sternum and costal cartilages appear depressed into the chest
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Spine
o Kyphosis forward bending of the vertebral column
o Scoliosis lateral bending of the vertebral column
o Kyphoscoliosis combination of both
Chest wall
o Barrel shape chest present or not
o In normal chest transverse diameter is more than the Ant. post diameter.
o The ratio is Trans : ant.-post = 7:5
o In barrel shape chest ant-post. Diameter is more then the transverse diameter
o It is found in emphysema.
How will u measure barrel shape chest
o Keep two hard broad both side of chest and measure the diameter in between them at level of
nipple it is transverse diameter
o Now keep two hard broad above and below of the chest and measure the diameter in between
them at level of nipple it is ant-post diameter
Cause of unilateral restriction

2. SEE ANY ASYMMETRY PRESENT OR NOT SUCH AS
Fibrosis
o Wasting
Collapse
o Flattening of chest,
Pleural effusion
o Dropping of shoulder
Pneumothorax
(These three occur due to fibrosis underlying lung)
Consolidation
o Swell of chest
Cause if bilateral restriction
Emphysema
If present please mention right or left side chest and upper or
Ankylosing spondylosis
Middle or lower part of chest
3. MOVEMENT OF THE CHEST

o Any restriction of movement present or not
If present then mention unilateral or bilateral restriction and
Upper part or lower part of the chest
How will u see this?
Sit down right side of the patient at such a position that your eye &
And chest wall remain same horizontal level
Then goes to the foot end of the patient again sit down in such way
That your eye and chest remain in same horizontal plane
5-8. Then seen
Now u stand up draw the attention of the examiners that you are looking at the neck, suprasternal ,
supra clavicular area , sub costal region
Now bend to see lateral surface of the left chest. And look for the following
9. Engorged vein present or not
If present then ask the patient to lift up his hand above the shoulder if vein become more
prominent it is due superior vena cava obstruction and see the direction of flow which will be
downward in case of SVO
10. Neck swelling SVO (non pulsatile neck vein engorged , conjunctival suffusion/ chemosis )
11. Intercostals fullness or recession / in drawing
12. Suprasternal , Supraclavicular excavation
13. Prominence of accessory respiratory muscle
14. Scar mark, visible impulse and pigmentation , spider nevi
15. Gynaecomastia and lip pursing
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4. RESPIRATORY RATE AND RHYMTH, PATTERN OF BREATHING

See respiratory rate and rhythm depth
How to see it ---
First look at your watch
Look at the patient for 15 sec and multiply the number respiratory rate with 4
Normally 14-18/min
Increased rate is called Tachypnoea > 20 / min and
Increased depth is called Hyperpnoea
Decreased rate or slow respiration is called bradypnea
What are the abnormal patterns of breathing such as :

Cheyne stokes breathing
Kussmaul breathing
Ataxic breathing
Apneustic breathing
Cause of tachypnoea Physiological

Anxiety
Exercise
Pathological cause
RTI (pneumonia and others )
Bronchial asthma , COPD , pulmonary embolism
Fever
Metabolic acidosis (DKA, uremia )
LVF
Function
CVA
Cause of hyper apenea Metabolic acidosis
DKA
Uremia
Decreased respiratory rate / Opioid toxicity,
bradypnea Hypothyroidism,
Raised intracranial pressure,
Hypothalamic lesions, and
Hypercapnia.
Cheyne stokes breathing
Cheyne-Stokes breathing is cyclical or periodic respiration is characterized by a period of increasing
rate and depth of breathing followed by diminishing respiratory effort and rate, usually ending in a
period of apnoea or hypopnoea. Then repetition of this cycle
It is occur due to diminish sensitivity of respiratory center to CO2
Cause
Brain stem stroke,
Severe cardiac failure./LVF
Coma
Necrotic poisoning
May be during sleep in the elderly.
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Kssmaul respiration
It is deep, sighing and rapid respiration at regular rate due to stimulation of respiration centre by P H
Cause metabolic acidosisis
K-DKA, U-uremia, SSsalicylic acid Mu--methanol poisoning . L- lactic acidosis
Ataxic breathing
o it is characterized by irregular respiration in time and depth
o Cause brain stem damage CVA or head injury
Apneustic breathing
o It is characterized by post inspiratory pause in breathing.
Cause:
Pontine damage
Palpation of the chest

In palpation you have to see following
Trachea
Tracheal tug
Apex beat
Chest expansion
o Symmetrical expansion see with both hand
o Gross measurement with measuring tap
Vocal fremitus :
First see trachea:
Step one. First place your index finger and ring
finger in sterno-clavicular joint
Step two : place middle finger just supra sternal
notch and gently press over trachea and feel it
Step three : Now gently place middle finger in
between right sternomastoids muscle and trachea
now Measure the distance between it and the right
sternomastoids
Step four : then do same thing on the left
Step five : Normally this distance is equal in both
side
.if found that your finger is easily
insert right side and
feel difficulty or tightness in
inserting to left side then
ur interpretation will be trachea is
shifted to tight side (right )
Now interpretation
Normally: trachea is central and slightly deviated toward the right
Trachea started from cricothyroid cartilage and bifurcated anteriorly at the level of
sternal agnle and posteriorly at the level of T4 vertebra
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Towards the side of the lung Central Away from the side of the
lesion / pulling lung lesion / push
collapse In normal Tension pneumothorax
fibrosis Consolidation Massive pleural effusion
Pneumonectomy
TRACHEAL TUG:
o Descend of trachea during inspiration Is called tracheal tug . it indicate hyper inflation of lung
Normally:
o The distance between the suprasternal notch and cricoid cartilage is normally three to four
finger breadths. (Crico-sternal distance )
o Reduction in this distance suggests lung hyperinflation or 'tracheal tug'
. How will you measure the tracheal tug:
Place three finger over trachea
Ask the patient to take deep breath while u r resting finger on the trachea
If patient have hyperinflation trachea will goes downward with each inspiration
So cricosternal distance will be less than three finger and u will tell that tracheal tug is present
Apex beat:
See cardiology
Chest expansion
We see chest expansion in two ways
1. With hand ---To see any asymmetrical expansion or restriction
2. With measuring tap total expansibility of chest
How will u see the expansibility with hand?
Both sides of the thorax should expand equally during maximal inspiration
Usually we see it in three positions
At menubrium sternum To see apical zone / upper
At nipple To see mid zone
Just above xephoid process ----to see lower zone
At apex / upper Zone
Step .1: Place u r both hand firmly (not tightly) on the patient chest in such a position that all
the extending fingers remain on the patients on the apex of lung
Step .2. : Now place your thumbs in such way that they touch each other in the mid line at
menubrium .
Step 3 : Look care fully that tip of thumbs do no touch the chest wall
Stop 4: Ask the patient to take a deep breath.
Step 5 : As they do this, watch your thumbs
Your thumbs should move symmetrically apart in normal case
If you look that one thumbs is moving less apart from other
Then it indicate that there is reduction expansion of chest on that side
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At the middle zone

Step .1: Place u r both hand firmly (not
tightly) on the patient mid chest in such a
position that all the extending fingers remain
on the mid lateral surface of the patients lung
Step .2. : Now place your thumbs in such
way that they touch each other in the mid line
at
Nipple level
Step 3 : Look care fully that tip of thumbs do
no touch the chest wall
Stop 4 : Ask the patient to take a deep breath
Your thumbs should move
symmetrically apart in normal
case
If you look that one thumbs is
moving less apart from other
Then it indicate that there is
reduction expansion of chest on
that side
Lower Zone
Step .1: Place u r both hand firmly (not tightly)
on the patient lower chest in such a position
that
all the extending fingers remain on the
lower lateral surface of the patients lung
Step .2 : Now place your thumbs in such way
that they touch each other in the mid line at
xephoid process
Step 3 : Look care fully that tip of thumbs do
no touch the chest wall
Your thumbs should move
symmetrically apart in normal
case
If you look that one thumbs is
moving less apart from other
Then it indicate that there is
reduction expansion of chest on
that side
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With measuring tap
Place the measuring tap in circumference around chest at level of nipple
Now ask the patient to take depth breath
Now measure how much the chest expand in inspiration
Normally it is more than 5 cm if it is less than 2 cm than I t restriction
Tenderness over the costal cartilages is found in the costochondritis of Tietze's syndrome
Vocal fremitus :
This is the vibration felt on the chest as the patient speaks
Usually it sees in three lines ()
Midclavicular ( up to 6th inter costal space )
Mid axillary line (up to 8th inter costal space)
Infra scapular line (posteriorly in sitting poison up to 10th inter costal space)
Anteriorly at mid clavicular line
Patient chest should be exposed (without cloth)
Both arms should be abducted to expose the
lateral surface of chest
Now start see vocal fremitus in following ways
o Place the medial edge of your hand
horizontally against the chest.
o Ask the patient to say one, one,
o You should feel the vibration against
your hand
o At mid clavicular line star from apex
Compare right and left
alternately such
Rt apex left apex, left 1st
ICS(inter costal spac)-Rt 1st ICS
, Rt 2nd ICSLeft 2nd ICS, left
3rd ICSRt 3rd ICS on ward
up to 6th ICS
Give special attention that
medial edge of your hand remain
on intercostals not over the rib
In lower part of the chest medial edge of the hand
should be placed in obliquely to keep hand in inter
costal space
o Now goes to mid axillary line :

o Do the same thing in following ways
Compare right and left alternately such
Rt 2nd ICSLeft 2nd ICS, left 3rd ICSRt 3rd ICS on ward up to 8th ICS
Give special attention that medial edge of your hand remain on intercostals not over
the rib
For this reasons place the hand obliquely so that it remain in inter costal space not
over the rib from the very beginning
NOW SEE LOCAL TENDERNESS
Over costal cartilage and ribs
Tenderness over the costal cartilages is found in the costochondritis of Tietze's syndrome
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Percussion
How will u do percussion?

Step one -- place the palm of your left hand on the chest with fingers separated and lying
between the ribs
Step two -- Press the left middle finger firmly against the chest
Step three-- Using the tip of the middle finger of the right hand, strike the centre of middle
phalanx of the middle finger of the left hand (The right middle finger should
be kept in the flexed position)
Step four There will be a loose swinging movement arising from the wrist and not the
Forearm
Step five--- The striking finger should be moved away again quickly as keeping it pressed
on the left hand may muffle the noise
Like vocal fremitus percussion is done in three lines

Midclavicular ( from apex up to 6th inter costal space )
How will u do percussion anteriorly in midclavicular line :
Both arms should be abducted to expose the lateral surface of chest
Start percussion in above mention way in following sequence
o First percussion over the left apex by placing your left middle finger over the
supraclavicular fossa and do it over the left apex.
o Now Percuss the left clavicle directly within its medial third and then do it in right
o On percussion on rt 1st ICS left 1st ICS then
o on rt 2nd ICS left 2nd ICS then
o On left 3rd ICS rt 3rd ICS thus do as Z pattern up to 6th ICS
o Always keep the finger over space not over the rib.
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Now percussion over lateral chest along the mid axillary line
o Do the same thing in following ways
Compare right and left alternately such as
Rt 2nd ICSLeft 2nd ICS, left 3rd ICSRt 3rd ICS on ward in Z pattern up
to 8th ICS
Give special attention that your finger main on intercostals not over the rib
For this reasons place the finger obliquely so that it remain in inter costal
space not over the rib from the very beginning
Auscultation
In auscultation we the following :

Breath sound
Add sound
Wheeze (rhonchi):
Crackles (crepitations)
Pleural Rub
Vocal resonance
BREATH SOUND AND ADD SOUND IS LISTEN SIMULTANEOUSLY

In three line
Mid clavicular ( from apex up to 6th inter costal space )
First along Mid clavicular :

Both arms should be abducted to expose the lateral surface of chest
Ask the patient to take deep breath
Now start auscultation from apex with the bell and rest of the area with diaphragm with
following sequence keep mind that never place stetchoscope at mid line or near to midline and
also over rid
o Compare right and left alternately such
o Rt-apex left apex, left 1st ICS(inter costal spac)-Rt 1st ICS , Rt 2nd ICSLeft 2nd
ICS, left 3rd ICSRt 3rd ICS on ward up to 6th ICS
o Stethoscope should be along mid calivicular line and over ICS not over rib
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Next over lateral surface over mid axillary line:
Do the same thing in following ways
Ask the patient to take deep breath
Compare right and left alternately such as
Start from Rt 2nd ICSLeft 2nd ICS, then left 3rd ICSRt 3rd ICS on ward
in Z pattern up to 8th ICS
Give special attention that your diaphragm of stethoscope remain on
intercostals not over the rib
Vocal resonance : Auscultatory equivalent of vocal fremitus.
All the procedures are same as listening breath sound

Only we here ask the pt to say one one / nine nine and you have to listen with with
stethoscope
We see it in three line and apex is listen when see the anterior surface at midclavicur line
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Now examine the patient from back:
Q. Sir asks u to do examination of respiratory system from the back?
Or if u ask to examination
Step 1: Introduced your self to the patient and take consent from the patient by telling that I m going
to examination u for my purpose, it will not hurt u. I can proceed.
Step 2 : ask to patient to sit down keeping the back toward you
Step 3 : Now expose the patient
Step 4 : position of patient patient should sit down and keep his right hand on left shoulder and keep
left hand on right shoulder exposing the both apex
Step 5. look the patients back from behind and
o look at the apex and also hand to see clubbing
o and bend right and left side to see later surface of the patient
Inspection:
See Any Asymmetry or deformity Present Or not
o Such as wasting or dropping of shoulder
o Deformity of spine such
Kyphosis
Scoliosis
Kyphoscoliosis
Movement Of The Chest
Any restriction of movement upper / middle / or lower zone
Evidence of respiratory distress
Intercostals fullness or recession / in drawing
Scar mark, visible impulse and Engorged vein present or not
spider nevi and pigmentation and fungal infection
Now Palpation
here only see two things
Expansibility of chest
Vocal fremitus
At apex
Step .1: Place u r both hand firmly (not tightly) on the patient chest in such a position that all
the extending fingers remain on the patients on the apex of lung
Step .2. : Now place your thumbs in such way that they touch each other in the mid line
Over the spine of vertebra and in between the thumb there skin in folded position .
Stop 4: Ask the patient to take a deep breath.
Your thumbs should move symmetrically apart in normal case
If you look that one thumbs is moving less apart from other
Then it indicate that there is reduction expansion of chest on that side
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At the middle zone

Step .1: Place u r both hand firmly (not tightly) on the patient mid chest in such a position that all the
extending fingers remain on the mid lateral surface of the patients lung
Step .2. : Now place your thumbs in such way that they touch each other in the mid line at
Over the spine of vertebra and in between the thumb skin remained folded position
Step 5 : As they do this, watch your thumbs for symmetrical movement
Lower Zone
Step .1: Place u r both hand firmly (not tightly) on the patient lower chest in such a position
that all the extending fingers remain on the lower lateral surface of the patients lung
Step .2 : Now place your thumbs in such way that they touch each other in the mid line
Over the spine of vertebra and in between the thumb there skin in folded position
Step 5 : As they do this, watch your thumbs for symmetrical movement
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SEE THE VOCAL FREMITUS
Now start see vocal fremitus in following ways

Place the medial edge of your hand horizontally against the
chest.
Ask the patient to say one, one,
You should feel the vibration against your hand
Place the hand sequentially in following way
Step 1. : 1st on right apex then on left apex
Step 2 : Over the trapezius muscle :
Here u have to do three times on both sides
Ist-- medial 1/3 --- on right then left side
2nd mid 1/3 ---on left then right side
3rd lateral 1/3 --- on right then left side

Step 3 : some prefer place hand over supra spineous process both
side to see fremitus / some not
Step 4 :
Now place hand three times along Para scapular lesion be care
full that ur hand remain in more laterally
1st -- right then left
2nd left then right
3rd right then left
Setp 5 :
Now place hand over infra scapular line (just below the angle of
scapula ) . be care full , keep hand obliquely that it remain in
intercostal space
1st -- right then left
2nd left then right
3rd right then left
Now do percussion
Method of percussion will be same as that
u learn in examination in lying position .
Sequence of percussion will follow the that
of vocal Fremitus
So see the box of examination of vocal
fremitus from the back
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In auscultation we listen the following:
Breath sound
Add sound
Wheeze (rhonchi):
Pleural Rub
Vocal resonance
Special attention :Avoid auscultation within 3 cm of the midline anteriorly or posteriorly as these areas
may transmit sounds directly from the trachea or main bronchi.
Method of auscultation / vocal resonance will
be same as that u learn in examination in lying
position.
Sequence of auscultation / vocal resonance
will follow that of vocal Fremitus
So see the box of examination of vocal
fremitus from the back
Remember
Apex should be auscultated with bell of the
stethoscope rest other are diaphragm
Stethoscope should be place in such a way
that it do not come in mid line so during
auscultation keep the stethoscope as laterally
as possible
How will u see the Basal crep (++):

By place diaphragm of the stethoscope but bellow the angle of scapula and ask the patient to take deep
breath. Listen for crep at end of inspiration
Listen it bilaterally
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Question on palpation
What are causes of increased vocal fremitus, vocal resonance, Bronchial breath sound?
Cause increased Vocal fremitus & Resonance Cause decrease vocal fremitus and resonance
,Bronchial breath sound ( 3CF)
Consolidation Pleural effusion
Collapse (peripheral/ with patent bronchus ) Central collapse (with out patent bronchus )
Cavitations Pneumothorax
Fibrosis Mass lesion
Thicken pleura
Interpretation of percussions note:
Resonance Over normal chest

Hyper resonant Pneumothorax
Emphysema
Dull Woody dull---consolidation

Collapse
Fibrosis
Thicken pleura
Stony dull Pleural effusion
Type of breath sound

Three type of breath sound found in
Bronchial
Vesicular
Vesicular breath sound with prolong aspiration
What is normal breath sound ?

It is vesicular breath sound
What r the cause bronchial breath sound ?
3 CF
Consolidation
Collapse (peripheral/ with
patent bronchus )
Cavitations
Fibrosis
Where breath sound is normally bronchial ?
Breath sound is normally present trachea ,larynx , at mid line
Describe the bronchial breath sound and draw its figure ?
See the box
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Type of breath Cause
sound
Bronchial high-pitched with a hollow or blowing 3 CF
quality Consolidation
Has two phase ,expiratory is more than > Collapse (peripheral/ with
inspiratory phase patent bronchus )
there are gap between inspiratory and Cavitations
expiratory Fibrosis
two type Normally found in
high pitched Trachea
o consolidation Larynx
o collapse with patent bronchus Midline
low pitch
o cavitations
Cause of decreased sound

Vesicular breath sound Normal breath sound Pleura effusion
Inspiration is louder & longer Thicken pleura
Expiration is shorter Pneumothorax
No gap between inspiration Central collapse (with out
and expiration patent bronchus )
Mass lesion
Vesicular breath sound with Usually pathological Cause

prolong expiration Inspiration is shorter COPD
Expiration is longer Chronic bronchitis
There is no gap between Emphysema
inspiration & expiration
Bronchial asthma
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What are the added sound u listen during auscultation
Added sound are :
Wheeze (rhonchi):
Pleural Rub
WHEEZE:/ RONCHI
It is the musical sound produced by passage of air throw narrow air ways
Patho :
Mucosal edema
Spasm of bronchial musculature
Type :
On intensity
Low pitch : Indicate large bronchi obstruction
High pitch : Indicate small bronchi obstruction
On phase of respiration
Inspiratory wheeze
Expiratory wheeze
Cause of wheeze:
Bronchial asthma
COPD
What are the cause of localized rhochi :

Patho: partial obstruction of large obstruction
Type:
Cause: To remember FMCfaridpur medical college
F---foreign body
MMucous plug
C ---carcinoma or bronchial neoplasm
CRACKLE
These are interrupted non musical the bubbling or crackling sounds occur due to passage of air through
the fluid fill alveoli
Patho :
Due to fluid in alveoli (pulmonary edema )
Reopening of collapsed alveoli at end of inspiration (Fibrosing alveolitis)
Type :
On basis of intensity
Fine creps Cause creps :
Fine
Coarse creps
On phase of respiration Pulmonary edema
Coarse creps
Inspiratory
Bronchiectasis
Expiratory
Fibrosing alveolitis / ILD
Both
Lung abscess
Cause of ends inspiratory creps ? Resolving pneumonia
Pulmonary edema COPD (chronic bronchitis )
Fibrosing alveolitis
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How will u differentiate between end-inspiratory creps of pulmonary edema and
Fibrosing alveolitis?
Creps of pulmonary edema change with coughing
Creps of fibrosing alveolitis does not change with coughing and also have clubbing
Name the condition where creps disappear after coughing?

Pulmonary edema
Bronchiectasis
Lung abscess
Resolving pneumonia
PLEURAL RUB
It is creaking sound likened to the bending of new leather or the creak of a footstep in fresh snow...
Patho:
Caused by inflamed pleural surfaces rubbing against each other.
When best heard:

Heard at the height of inspiration
Disappear in breath hold
Pleural augment by the pressing the stethoscope
Causes: it indicate pleurisy
Pneumonia,
Pulmonary embolism with infarction.
How will u differentiate between pleural rub and creps
Pleural rub Creps

1. Pain full Pain less
2. Not change with cough Change after coughing
3. Augmented by pressing stethoscope Not so
4. It is creaking or rubbing sound It is bubbling or cracking sound
5. Due rubbing of inflamed pleura Fluid in alveoli or reopening of collapsed alveoli
In viva 1st answer 1 and 2 then u may say next others
How will u differentiate between pleural rub and pericardial rub?
Pleural rub Pericardial rub

1. Any where of the chest Only over the pericardium (better left lower para
sternal )
2. Absent when respiration is ceased No relation with respiration
3. Occur due to pleurisy Occur due to pericarditis
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Vocal resonance:
It is the auscultatory equivalent of vocal fremitus.
Consolidated lung conducts sounds better than air-containing lung, so in consolidation the vocal
resonance is increased and the sounds are louder and often clearer
It is three types
Bronchophony ---
It appear to be near the ear piece &
Ask the patient to say "ninety-nine" several times in a normal voice
The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called
bronchophony.
Cause Consolidation
Egophony
It is the nasal quality or goat like sound (aix-means goat and phony-means sound )
Found in --consolidation & Upper level of pleural effusion
Caused -- It is due to enhanced transmission of high-frequency noise across abnormal lung with lower
frequencies filtered out.
Whispered Pectoriloqny--
Place stethoscope over chest and Ask the patient whispers a phrase (e.g. 'one-one')
You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as
whispered pectoriloquy
Found in --Consolidation
Increased vocal resonance Diminish vocal resonance

3 CF(like bronchia sound & V. fremitus ) Pleura effusion
Consolidation Thicken pleura
Collapse (peripheral/ with patent bronchus ) Pneumothorax
Cavitations Central collapse (with out patent bronchus )
Fibrosis Mass lesion
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You have to know chest finding in different situation which frequently ask in viva
Pleural effusion
Inspection Restriction of movement of right

lower and middle chest .
Palpation Trachea is deviated toward left
Chest expansibility reduce on
right mid and lower Zone
Vocal fremitus diminish in right
and mid zone
Percussion Stoney dull on right mid and lower
Zone
Auscultation Breath sound is diminish / absent &
Vocal resonance absent or decreased
On right mid and lower Zone
Consolidation (right upper ZONE)
Inspection Restriction of movement of right upper chest
Palpation Trachea is in central

Chest expansibility reduce on right upper
Zone
Vocal fremitus increased right upper Zone
Percussion Woody dull on right right upper Zone
Auscultation Breath sound is bronchial &

Vocal resonance increased
On right right upper Zone
Peripheral collapse (with patent bronchus ) right upper Zone
Palpation Trachea is deviated to the right

Chest expansibility reduce on right upper Zone
Vocal fremitus increased right upper Zone
Percussion dull on right right upper Zone

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Central collapse (with out patent bronchus ) right Zone

Chest expansibility reduce on right upper Zone
Vocal fremitus diminish or reduced on right
upper Zone
Percussion Dull on right right upper Zone
Auscultation Breath sound is absent or diminish &

Vocal resonance absent diminish
Fibrosis of Right upper Zone

Wasting ,flattening , dropping of shoulder
Chest expansibility reduced on right upper
Zone
Vocal fremitus increased on right upper
Zone
Percussion Dull on right upper Zone

On right upper Zone
Right sided Pneumothorax
Inspection Restriction of movement of right side of chest
Palpation Trachea is deviated to the left

Chest expansibility reduce right side
Vocal fremitus diminish or reduced right side
Percussion Hyper resonance on right side
Auscultation Breath sound is absent or diminish &

Vocal resonance absent diminish
On right side of chest
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How will u differentiate between fibrosis and collapse (peripheral collapse )
Fibrosis Collapse
Fibrosis is a long standing process that why. This are absent or if present then are less
wasting of chest muscle , marked
Flattening chest and
Rib crowding
are more marked on fibrosis then collapse
Radiological---non homogenous opacity Homogenous opacity
How will you describe after respiratory system examination:
Examination of this old cachetic patient reveals that size and shape of the chest wall is normal there
is wasting and flattening of right upper chest. Restriction of movement of right upper chest
.respiratory rate is 15 / min with normal rhythm and pattern .There is no supra sternal , supra
clavicular or intercostals recession . There are pachy hypo pigment areas over left middle chest and
a scar mark over right lower chest
On palpation Trachea is grossly deviated to the left ,Chest expansibility reduce on upper right
side .Vocal fremitus increased on right side
Anteriorly up to 4th intercostals space
Laterally up to 5th intercostals space
Posteriorly up to 7th intercostals space
And rest of chest is normal
On percussion reveals dull on above mentioned areas and rest of the areas are normal
On auscultation reveal bronchial breath sound with coarse inspiratory and expiratory creps
which change after coughing.
Breath sound on remaining part of the chest is vesicular
Vocal resonance is increased in above mentioned area and rest of the chest are normal
So my clinical diagnosis is fibrosis of right upper chest
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Short case one ---u will get pleural effusion or normal chest
Ask to examine anteriorly or from the back
A short case ----right sided pleural effusion

Do according to procedure
Never miss to mention about any pigmentation , scar mark ,fungal infection , any bandage or
canula or aspiration marks .
Examination of respiratory system Examination of this old cachetic patient reveals that size and shape of
the chest wall is normal .There is restricted Chest movement in Rt lower part and respiratory rate is 15 /
min with normal rhythm and pattern .There is no supra sternal , supra clavicular or intercostals recession .
Trachea: deviated to the left (may be Central in position). Apex beat: normal ,
Decreased expansibility of right lower chest
Vocal fremitus : Diminished from
Anteriorly Right 5th intercostal space to downwards along midclavicular line And
laterally Right 6th intercostal space to downwards along midaxillary line and
posteriorly Right 7th intercostal space to downwards along infrascapular line &
Normal in other part of the chest.
Percussion: reveals Stony dull. Breath sound absent, and vocal resonance Diminished at above mentioned
area. And rest of area are normal with vesicular breath sound . ther is no added sound
My clinical diagnosis ----right sided pleural effusion
Why u called it pleural effusion?

Trachea shift to left side (only in massive effusion )
Percussion stony dull
Vocal resonance and Fremitus --- decreased
Breath sound ---- decrease
Why this not a case of consolidation ?
In Consolidation
Trachea central and
breath sound bronchial,
Vocal resonance and Fremitus --- increased
Percussion woody dull
cerps +
Why this not a case of fibrosis
Fibrosis
Trachea same side and
breath sound bronchial
Vocal resonance and Fremitus --- increased
wasting of over lying chest ,
Rib crowding present ( space between corresponding rib is decrease )
Why this not a case of collapse

If bronchus is patent
23
Trachea same side
Bronchial breath sound
If bronchus is not patent
Trachea same side
Breath sound diminish
How will u confirm the pleural effusion at bed side ?
By aspiration of fluid
How color of fluid help in Diagnosis ?
Color
straw TB
Turbid / pus pneumonia /empyma
Hemorrhagicca bronchus
Serous -- transudative
Maximum aspiration per day is ?
1.5 L
removing more than 1.5 litres in one episode is inadvisable as there is a small risk of re-expansion
pulmonary oedema..
Amount of fluid
Pleural effusion is clinaclly detect if Fluid is
500 ml
Radiological detected in PA view if Fluid is
200 ml
Radiological detecte in Lateral view if Fluid is
100 ml
USG can detect as small amount Fluid
What may be the cause of pleural effusion in this patient

Sir want to do some relevant such as
I want to see clubbing ,
Cervical lymph node
Feature of horners syndrome (,Ipsilateral partial ptosis,Enophthalmos, anhydrosis )
Hoarseness of voice
Feature of SVC obstruction
If these are present then it will be bronchogenic carcinoma other wise TB
Causes for an exudative pleural effusion Causes of a transudate:
To remember PTCL
Tuberculosis (T) Nephrotic syndrome.
Bronchogenic carcinoma (C). Cardiac failure.
Pneumonia.(P) Liver cell failure.
Pulmonary infarction. Hypothyroidism.
Lymphoma (in young individuals)., (L)
Mesothelioma.
Connective tissue disease RA,SLE
24
Cardiovascular system examination
EXAMINATION OF CVS
It is consist of
Peripheral pulse ,
BP,
JVP ,
Examination of precordium
First examination of precordium
Inspection
Palpation
Percussion
Auscultation
Step one---- first give salaam and introduced your self to the patient & tell the patient that I am going to
examine you for my purpose and it will not hurt you. May I proceed?
Step two ---Now expose the patient
Step three---now inspect chest
Inspection please see the following
1. Size And Shape and any deformity of the Chest Wall
2. Visible impulse
a. Cardiac impulse &
Usually u may see visible impulse in precordium or apical region /
b. Other impulse
Please look for visible pulsation in other area
epigastric pulsation
suprasternal and supraclavicular pulsation
3. Scar mark, Engorged vein present or not , pigmentation---hypo or hyper pigmentation or
fungal infection
4. Other Neck swelling SVO, Gynaecomastia and spider nevi and pigmentation
What r the cause of epigastric Cause of suprasternal pulsation

pulsation?
Aneurysm of abdominal aorta Aneurysm of arch of aorta
Pulsatile liver (TR) Aneurysm of ascending aorta
Right ventricular hypertrophy
COPD or pulmonary HTN
Lean and thin person
Mass over lying abdominal
aorta
CVS 25
Palpation
In palpation we will see the following
Apex beat
Trachea
Left parasternal heave
Palpable P 2
Thrill
First we will see the apex beat

Remember we will see sitespace, distance---away from mid line and character
1. First keep the measuring tap on the bed from

your pocket as it will need later to measure
distance of apex beat from mid line
2. Place the flat surface (palm) of your right hand
just bellow the nipple try to feel any cardiac
pulsation present or not.
3. It is better to place the hand more laterally and
goes medially to find apex beat
4. Either u got apex beat or not roll the patient left
laterally
a. if u got the apex beat previously then it
help u to confirm the apex or
b. if can not locate the apex it help you to
located the apex beat
5. Now return the patient in his previous position
and localize the apex beat with single finger.
6. Now with the thumb or index finger of left hand
please first identify the sternal angel
a. if u rub your finger from manubrium
sternum to down ward u will find ridge
or elevated area it is the sternal angle
7. Go left laterally & you will find 2nd rib and
below its 2nd inter costal space and count the
space to up to apex beat where your finger is
still placed
8. Now take the measuring tap and measure the
distance from mid line to apex beat in cm
9. in the mean time u look the character of apex
beat .
Trachea :
Like that of in respiratory system
CVS 26
Left para sternal heave
1. place your plamer surface right hand or

ulnar border of right hand over left
parasternal region
2. if left para sternal heave present then u will
find
a. this is a sustained, thrusting pulsation
usually felt at the left sternal edge
indicating right ventricular enlargement
Now palpable see P2

1. First identify the pulmonary area which
is in left 2nd inter costal area
2. Place vertically the tip of right fingers in
that area
3. If u find / feel any pulsation or cardiac
beat ---it is palpable P2
Thrill
Palpable murmur is called thrill
How its feel? It feels rather like placing your hand on a purring cat
Which part of hand is used to see thrill? Ball of finger.
1. Patient will be in lying position If u got thrill in mitral area , u have to see it in
2. we examine the thrill in 4 area left lateral position in breath hold expiration .
a. Mitral
b. Tricuspid or left lower sternum or
sternal edge If u got thrill in in aortic and tricuspid area ,
c. Aortic area Sit down the patient and see it in leaning
d. Pulmonary area forward & birth hold expiration .
3. we use ball of fingers of right hand to palpate it

4. During palpation of thrill keep Ur left thumb
on carotid pulse.
5. Now start from mitral area if found then roll the
patient in left lateral position
6. Now place your hand in lateral to left lower
sterum or tricuspid area
7. Now see thrill with ball of finger of right

hand over aortic area & pulmonary area
CVS 27
Percussion
Usually it is not practice
In percussion we area of the superficial cardiac dullness
Patient should be in lying position
1. In this percussion we will identify the area of
superficial cardiac dullness
2. For this u have to identify a tri angle that has
three border
a. Right border of hear that is form by the
right atrium ,
b. base or superior border of heart that is
form by the great vessel
c. Inferior border of heart that is formed
by apex or left ventricle
3. so u have to percussion in three direction to find
out this three border
4. First right border
Percussion vertically from right nipple to midline
until dullness appear . where will u get the dullness
, u will immediately stop there because it will be
the right border of heart
5. Now base or superior border
percussion obliquely just bellow the left shoulder
toward the xephoid process until dullness appear
and stop immediately when u will get the dullness
and it will be the superior border or base
6. Now see the inferior border
percussion obliquely from left lower chest toward
the left nipple or apex until dullness appear and
stop immediately when u will get the dullness and
it will be the inferior border of heart .
7. The area among these three borders is the area

of superficial cardiac dullness.
8. after percussion u have to comment that this
area of cardiac dull ness is
Normal or
Increased (in pericardial effusion )
Decreased (emphysema )
Auscultation of precordium (What will u see in auscultation of cardiovascular system)

Heart sound Added sound
Normal heart sound . Murmur
1 heart sound
st
Opening snap.
2 heart sound
nd
Ejection clicks
Abnormal heat sound Pericardial rub
3 heart sound
rd
4th heart sound
CVS 28
Auscultation of precordium done in 4 areas these are
Name of Location
the area
Mitral Left 5th intercostal space in the mid-
clavicular line (the apex).
Tricuspid : 3rd and 4th intercostal space at the left
sternal edge/ para sternal area
Pulmonary : 2nd intercostal space at the left sternal
edge.
Aortic : 2nd intercostal space at the right sternal
edge
If you are ask to do only percussion then you have to

locate apex beat first to identify the mitral area. but here
no need to count space and measure distance from the mid
line
Before auscultation please try to remember the following rule
1. during all stage of auscultation left thumb should always remain in right carotid artery
2. diaphragm is used in all stage of auscultation except the two condition where bell is used
a. one to see the MDM of MS
b. to see carotid bruit
3. All heart sound listen in lying position. No need to sit the patient if no added sound / murmur
4. Murmur is listen in two position

a. In lying position ---(1)Mitral area ___MS & MR and (2) Tricuspid area___TR and VSD
b. In sitting position ----(1) Aortic are AS , (2) Tricuspid area AR , (3) pulmonary area PS
c. Murmur of MS seen in left lateral position
5. All the murmur listen in breath hold expiration expect murmur in pulmonary area (PS)which hard
breath hold inspiration
6. Radiation seen in two area in two murmur

a. In mitral area in murmur of MRradiation seen from Mitral area to Axilla
b. In aortic areain murmur of AS Radiation seen aortic area to angle of right jaw over the
carotid .
CVS 29
First listen heart sound
1. First identify the apex beat if do not do it in

palpation
2. Sow place left thumb should always remain in
right carotid artery
3. Now place your diaphragm following direction
in sequentially
a. Mitral area (at apex )
b. Tricuspid area(3rd / 4th left intercostals
space just lateral to sternum )
c. Aortic area (right 2nd intercostals space
just lateral to sternum) Mitral area (at apex )
d. Pulmonary area (left 2nd intercostals
space just lateral to sternum ) here ask
patient to take deep breath to see
splitting
Aortic area
Tricuspid area
Pulmonary area
CVS 30
You have to listen murmur
Murmur in mitral area
1. First in lying position (murmur of MS & MR)

2. keep left thumb should always remain in right
carotid artery
3. Now place your diaphragm in mitral area to see
murmur if found then
4. Roll the diaphragm and now place the bell of
stethoscope on mitral area
5. Now roll the the patient in left lateral position
and ask the patient for breath hold expiration
and with bell listen the murmur (MS)
6. Now return the patient in previous position and
with diaphragm see any radiation of murmur
from mitral area up to axilla (MR)
Murmur in tricuspid area
Now place diaphragm of the stethoscope in

tricuspid area and try to hard any murmur present
or not
Here no radiation seen

No matter of respiration
No posture change
Here just place the stethoscope and see any

murmur present or not
Aortic area
1. Now ask the patient to sit down and leaning

forward
2. keep your left thumb should as usual in right
carotid artery
3. Now ask the patient for breath hold expiration
4. Place diaphragm of stethoscope in aortic area
5. Now with the diaphragm see the radiation of
murmur (AS)from aortic area to just below
angle of right jaw over right neck
6. it better during listening radiation turn the
patient s head toward the left and removed the
that was over the carotid pulse
CVS 31
Now left lower sternal edge
1. The patient will still sit down and leaning

forward
2. your left thumb also remain over the right
carotid artery as usual
3. Now ask the patient for breath hold expiration
4. Place diaphragm of stethoscope in tricuspid
area
5. listen for murmur
Now pulmonary area
6. The patient will still sit down and leaning

forward
7. your left thumb also remain over the right
carotid artery as usual
8. Now ask the patient for breath hold
inspiration
9. Place diaphragm of stethoscope in
pulmonary area
10. listen for murmur
CVS 32
Procedure of examination of JVP
1. ask the examiner that I need back rest to

keep the pt in 45 0 position
2. Then the examiner will told ok take it or ok I
can not give u the back rest. pl examination
with available facility
3. Ensure that the neck muscles are relaxed by
resting the back of the head on 1 or 2 pillow
4. Look across the neck from the right side of
the patient
5. Identify the internal jugular pulsation
6. For confirmation do the abdomino-jugular
reflux (keep the right hand just bellow the
right costal cartilage & give upward pressure
it will make JVP prominent )
7. Estimate the vertical height in centimetres
between the top of the venous pulsation and
the sternal angle to give the venous pressure
8. this is done in following way
9. keep one scale vertically on angle of louis
and keep another scale horizontally at the
highest point of venous pulsation in such a
way that they will met with each other at 900
10. Now measure vertical height from angle of
Louis to the point of intersect
11. normally it will be not more than 4 cm
12. if it is more than 4 cm than u will tell that
JVP is raised
Mean right atrial pressure is normally < 7 mmHg (9 cmH2O).

Since the sternal angle is approximately 5 cm above the right atrium the normal jugular venous
pulse should extend not more than 4 cm above the sternal angle
Ventricular a wave = atrial systole
Systole Diastole C wave = transmitted carotid pulsation
X decent = atrial relaxation
V wave = closure of tricuspid valve
Y decent = ventricular filling as

tricuspid valve opens
CVS 33
what r the cause of raised JVP ?
Congestive cardiac failure./ corpulmonalae
Tricuspid regurgitation (prominent 'v' waves ).
Tricuspid stenosis (prominent 'a' waves).
Complete heart block (cannon waves).
Pericardial effusion
Pericardial constriction
Non-pulsatile neck veins seen in superior venal caval obstruction
Abnormalities of the jugular venous pulse ?
Absent 'a' waves Atrial fibrillation

Giant 'a' waves Tricuspid stenosis
Giant 'v' waves Tricuspid regurgitation
'Cannon' waves Complete heart block
Elevation. Kssmaul's sign Pericardial constriction
Elevation, loss of pulsation Superior vena caval obstruction
What are the difference between the venous pulsation or arterial pulsation ?
Jugular Pulsation Carotid Pulsation

2 peaks (in sinus rhythm) 1 peak
Impalpable Palpable
Obliterated by pressure Hard to obliterate
Moves with respiration Little movement with respiration
I
Why we see JVP in internal jugular vein than to external jugular vein?
There are no valves between the right atrium and the internal jugular vein. The degree of distension of
this vein is therefore dictated by the right atrial pressure, and the venous waveform provides
information
The external jugular vein is more superficial and prominent. Do not examine this routinely because it
is prone to kinking and partial obstruction as it traverses the deep fascia of the neck.
What is Kussmaul's sign?
It is paradoxically increased JVP in inspiration . Normally there is an inspiratory decrease in JVP. In
constrictive pericarditis there is an inspiratory increase in JVP. Kussmaul's sign is also seen in severe right
heart failure. It is caused by the inability of the heart to accept the increase in right ventricular volume
without a marked increase in the filling pressure
CVS 34
Examination of peripheral pulse
In peripheral pulse examination we see the following pulse :
Radial artery
Brachial artery
Carotid artery
Femoral artery
Popliteal artery
Antetior tibial artey
Posterior tibial artery
Dorsalis pedis
In examination of pulse what will u see?
Rate
Rhythm
Volume
Character
Radio-radial delay
Radio-femoral delay
Rate and rhythm seen radial artery
Volume and character is seen in carotid artery
Examination of pulse
Radial pulse
1. hand shake with patient with the right hand
2. if u do it the hand will automatically remain in
semiprone and semiflex position
3. Place your three middle fingers over the right
radial pulse.
a. ring finger will regulate the pulse
b. middle finger will feel the pulse
c. index will prevent retrograde pulsation
4. Count the pulse for 15 seconds and multiply by
four to obtain the pulse rate in beats per minute
5. The radial pulse is found at the wrist, lateral to
the flexor carpi radialis tendon and medial to
the radial styloid process at the wrist.
Radio-radial and Radio-femoral delay

To see radio-radial delay
1. Now palpate the left radial pulse with right
three finger to detect any radio-radial delay
presetn or not
CVS 35
To see radio-femoral delay
2. Now place right hand just below the mid
inguinal region to see femoral pulse and
simultaneously keeping the left hand on right
radial pulse
Brachial pulse
3. Use your thumb (right thumb for right arm and
vice versa) with your fingers cupped round the
back of the elbow
4. Feel medial to the tendon of the biceps muscle
to find the pulse and assess its character.
5. Feel medial to the tendon of the biceps muscle
to find the pulse and assess its character.
Carotid pulse
1. Never compress both carotid arteries
simultaneously.
2. Use your left thumb for the right carotid pulse
and vice versa.
3. when you see the right carotid pulse ask the
patient to turn head toward the left
4. Place the tip of your thumb between the larynx
and the anterior border of the
sternocleidomastoid muscle.
5. Press your thumb gently backwards to feel the
pulse
Location of femoral pulse
1. The femoral artery is situated just below the

inguinal ligament at the mid-inguinal point
which is midway between the anterior superior
iliac spine and the pubic symphysis
2. The pt will be in supine position firmly press
downwards at mid inguinal point using two or
three extended fingers.
CVS 36
Popliteal pulse usually not palpable
1. The patient should lie on a firm comfortable

surface so they can relax their muscles.
2. Flex the patient's knee to 30.
3. Keep your both thumbs in front of the patients
knee and rest of your fingers behind popliteal
fossa
4. Press firmly in the midline with your finger s
over the popliteal artery.
5. By sliding your fingers 2-3 cm below the knee
crease it may be possible to compress the artery
against the back of the tibia
Anterior Tibial artery
1. Patient will b in lying position

2. Place your index and middle fingers in between
medial and lateral malleolus
3. Now try to feel the pulse
Posterior tibial artery
4. Patient will b in lying position

5. place your index and middle fingers 2 cm
below and 2 cm behind the medial malleolus &
press against the bone to feel the pulse
CVS 37
Artery dorsalis pedis
1. The dorsalis pedis artery is the continuation of

the anterior tibial artery on the dorsum of the
foot
2. It passes lateral to the tendon of extensor
hallucis longus and is best felt at the proximal
extent of the groove between the first and
second metatarsals
3. First place index , middle and ring finger in the
middle of the dorsum foot lateral to the tendon
of extensor hallucis longus .
4. Be careful that your fingers should remain in
the grooves between the first and second
metatarsals
5. if u still cannot find the or feel the pulse please
extend the great toe against resistance . it will
make the tendon prominent & now feel the pu
Collapsing pulse
1. Patient should be in lying position

2. Ask the patient if there any pain in the elbow or
shoulder joint.
3. Now grasp the right hand of the patient with
your left hand
4. Now with your right hand grasp right forearm
just below wrist joint in such a position that the
ball of the right finger will remain over remain
over the radial pulse
5. Now fell the pulse with the ball of the right
finger for few second
6. Then suddenly raised the patient s arm above
the head or heart level
7. Now feel the pulse for few second
CVS 38
Classify the pulse? Pulse is classified in following way
A Anacrotic Slowly rising & small volume pulse Aortic stenosis
A Pulsus alternans an alternating strong and weak pulsation LVF

B Pulsus bisferiens Double peak of pulse , combination of AS with AR
slow rising and collapsing pulse
C collapsing Rapid upstroke and descend of pulse. the AR,
pulse which feels as though it suddenly hits Hyperdynamic circulation
your fingers and falls away just as quickly PDA
and seen by raising the arm above the head . Rupture of sinus of
Valsava
Large A-V fistula
W waterhammer Collapsing pulse of AR is called water AR

hammer pulse
P Pulsus paradoxus When volume of pulse reduce in inspiration Pericardial effusion
and increase in expiration then it is called Chr.constrictive
pulsus paradoxus .it is the exaggeration of pericarditis
normal phenomenon . Acute severe asthma
Massive pulmonary
embolism
J Jerky pulse : Hypertrophic cardiomyopathy
Cause of sinus tachycardia? Cause of sinus bradycardia?
Fast heart rate (tachycardia, > 100/min) Slow heart rate (bradycardia, < 60/min
Physiological Sinus bradycardia

o Exercise o Sleep
o Pain o Athletic training
o Excitement/anxiety o Hypothyroidism
Hyper dynamic circulation o Medication:
o Fever Beta-blockers
o Hyperthyroidism Digoxin
Medication: Verapamil, diltiazem
sympathomimetics Pathological
vasodilators Carotid sinus hypersensitivity
Pathological Sick sinus syndrome
o Atrial fibrillation Second-degree heart block
o Atrial flutter Complete
o Supraventricular tachycardia
o Ventricular tachycardia
CVS 39
What are causes of irregular pulse?
Irregularly irregular
o Atrial fibrillation
o Atrial flutter with variable response
o Multiple ectopics
Regularly Irregular
o Sinus arrhythmia
o Second-degree heart block Type I
o Ventricular extrasystoles
Cause of high volume ? Cause of low volume pulse?

AR Shock
Hyperdynamic circulation Aortic stenosis
o Fever Pericardial effusion
o Pregnancy and Pulmonary hypertension
o Thyrotoxicosis
PDA
ATRIAL FIBRILLATION
Cause of atrial fibrillation to remember it MITHA If sir want what else then you tell the following
Mitral valvular heart disease
Ischaemic heart disease Alcohol
Thyrotoxicosis Cardiomyopathy
H-hypertension Congenital heart disease
A-Lone / idiopathic Chest infection
This are the important cause first told only this Pulmonary embolism
Pericardial diseas
Treatment of AF ?
If cardiac compromised if following are present Drugs For AF
Rapid ventricular rate A- Amidarone (rate control )
SBP<90 mm of Hg B- Beta-blocker (rate @ rhythm control)
Heart failure Metaprolol
Impaired consciousness C- Calcium channel blocker (rate control)
TREATMENT is immediate cardioversion Verapamil or
Diltiazem
If not cardiac compromised D--Digoxin (rate controlin structural heart
Treatment is Disease such as MS )
Rate control If Thrombo-Embolism
Rhythm control Low molecular heparin (Inj.Cardinex , Claxane )
Revert to sinus rhythm 1 unit / kg B-wt SC bd for 5 days .
Then
Tab. Warin 5 mg or 2.5 mg
0 + 0 + 1 for 6 month ( maintain INR 2-3)
CVS 40
Question on CVS
Q.1., what are the causes of impalpable apex beat?
To remember DOPER
DDextrocardia
OObesity
PPericardial effusion
EEmphysema
RBehind the rib
Q. what are cause of shifting apex beat?

Normally apex remained 9 cm away from the mid line
Shift toward the left Shifted toward the right :
Due to heart cause : Lung cause :
Cardiomegaly Due to pushing :
LVH---Apex shifted downward and laterally Left sided pleural effusion
RVH---Apex shifted laterally Left sided pneumothorax
Lung cause : Due pulling effect :
Due to pushing : Fibrosis and collapse of right lower Zone
Right sided pleural effusion
Right sided pneumothorax
Due pulling effect :
Fibrosis and collapse of left lower Zone
What will u see during examination (palpation) of apex beat?

Site ,Distance & character
How will you describe the apex beat after palpation ?
Apex beat is located in left 5th intercostal space 9 cm away from midline which is normal in character
What r the character of apex beat?

Character Example
Normal
Abnormal
Heaving Forceful ,sustained and lift up finger Due to pressure overload
LVH due to
AS
Systemic HTN
Thrusting Forceful, less sustained and lift up finger Due to volume overload
Left ventricular dilatation
MR &AR
Tapping Neither forceful nor sustained and not Mitral stenosis
lifted up finger
Double apical impulse Hypertrophy cardiomyopathy
Ventricular aneurysm
Diffuse apex beat Ant. MI
Left ventricular aneurysm
CVS 41
Name some condition where u may get left parasternal What is the feel of it?
heave?
Cause is right ventricular hypertrophy due to : This is a sustained, thrusting pulsation
Pulmonary HTN usually felt at the left sternal edge
Corpulmonale indicating right ventricular enlargement
Pulmonary stenosis
Pulmonary regurgitation
Tricuspic regurgitation
Name the condition where you may get palpable P2 ?

Palpable P2 is found in pulmonary hypertension
Name the condition where u may got epigastric Name some condition where area of superficial
pulsation ? cardiac dull ness increased or decreased ?
Aneurysm of abdominal aorta Increased :
Pulsatile liver (TR) Pericarcial effusion
Right ventricular hypertrophy Cardiomegaly (dilated cardiomyopathy )
Lean and thin person Decreased :
Mass over lying abdominal aorta Emphysema
Pneuomthorax
Q. write down the difference between first and 2nd heart sound
1st heart sound 2nd heart sound
Due to closure of mitral and tricuspid valve Due to closure of aortic and pulmonary valve
Low intensity High intensity
More duration Less duration
Coincide with carotid valve Just follow the carotid pulse
Splitting absent Splitting present
Write down cause of loud first sound ? Write down cause of loud 2nd heart sound ?
Loud first heart sound Loud 2nd heart sound :
Mitral stenosis (only one answer ) Systemic HTN
If sir want to know more then Pulmonary HTN
Tricuspid stenosis
Hyperdynamic circulation
Write down the cause of soft 1st heart sound ? Write down cause of soft 2nd heart sound?
Soft 1st heart sound (RMC) Soft 2nd heart sound
RMitral regurgitation Calcified or severe aortic stenosis
MMyocarditis Severe pulmonary stenosis
C ---Cardiomyopathy Aortic regurgitation
Q what will be the intensity of 2nd heart sound in aortic stenosis ?

2nd heart will be soft
CVS 42
Patho-physiology of splitting :
During inspiration During expiration :

There is negative pressure in the thorax Lung expand
--cause --cause
Increased venous return Pulmonary capillary also expand
cause --cause
Increased right ventricular end diastolic volume Increased capacity of pulmonary circulation
cause --cause
So delayed closure of pulmonary valve Blood pooling into pulmonary Vessel
You will get splitting --cause
Decrease venous return into left atrium
--cause
Decrease left ventricular end diastolic volume
--cause
Early closure of aortic valve
Q cause of wide splitting

Widens in inspiration (enhanced physiological
splitting :
Right bundle branch

Pulmonary stenosis
Pulmonary hypertension
ventricular septal defects
Q cause of reverse splitting

Cause of reverse splitting
Aortic stenosis
Hypertrophic cardiomyopathy
Left bundle branch block
ventricular pacemaker
Q. wide and fixed splitting

Cause of wide and fixed splitting
Atrial septal defect
CVS 43
Causes of a third heart sound Cause of 4th heart sound ? (do not read )
Physiological A fourth heart sound may be heard in
Athletes Left ventricular hypertrophy,
Pregnancy Hypertension and
Fever Aortic stenosis.
Pathological
LVF
What is murmur ?
Murmur is the abnormal sound produce by either normal amount blood passing through abnormal valve
or increased or abnormal amount of blood passing through the normal valve
Classify the murmur?

Systolic murmur Diastolic Continuous
1. Ejection systolic 1. Early diastolic 1. PDApatent ductus
2. Pansystolic 2. Mid diastolic arteriosus
3. Late systolic
Give some example of systolic murmur

Pan systolic murmur
1. Mitral regurgitation
2. Tricuspid regurgitation
3. Ventricular septal defect
Ejection systolic
Aortic stenosis
Pulmonary stenosis
Late systolic
Left atrial myoxma
Give some example of diastolic murmur

Early diastolic
Aortic regurgitation
Pulmonary regurgitation
Mid diastolic
4. Mitral stenosis
5. Tricuspid stenosis
CVS 44
Name 5 cause of mid diastolic murmur ?
1. Mitral stenosis 4.Carey comb murmur (Mitral valvulitis in rheumatic fever )
2. Tricuspid stenosis 5.ASD
3. Left atrial myxoma 6.Austin flow murmur
Write down the feature of benign or innocent mumur?

Soft
Mid systolic
Heard at left sternal edge
Nor radiation
What will u see during describe a murmur

1. Character (Ch)
MS-- rough , rumbling,
MR--- Loud ,blowing
AR------ High pitch blowingh
AS- ---Harsh , high pitched and musical
VSD
ASD
PAD-- Loud, continuous 'machinery' murmur , train in tunnel
2. Intensity or loudnesssee the grading (I)
3. Timing --Systolic / diastolic (T)

4. Radiation (Ra )
MR----toward the axilla
AS ----towarr to right neck
5. Relation with respiration (Ranjan)
Right sided murmur increased in inspiration (PS , TR )
6. left sided murmur increased in expiration Site or location--- (Sir)
MS & MR---Mitral area
AR------tricuspid area
AS----aortic area
PS ----pulmonary area
TR &VSD---tricuspid area & left lower parasternal area (3rd &4th space )
PAD
To remember it Chitra ranjan sir
Classify the loudness of murmur ?

Grade 1.Heard by an expert in optimum conditions
Grade 2--Heard by a non-expert in optimum conditions
Grade 3---Easily heard; no thrill
Grade 4---A loud murmur, with a thrill
Grade 5---Very loud, often heard over wide area, with thrill
Grade 6---Extremely loud, heard without stethoscope
CVS 45
MS Low pitched , localized , rough , rumbling,

Mid diastoslic murmur ,
Best heard with bell of stethoscope in left lateral position and breath hold expiration
MR Loud ,blowing in character ,

Pansystolic murmur best heard at the apex radiate to axilla
AS Harsh , high pitched and musical

Ejection systolic murmur
usually audiable all over the precordium but more prominent is aortic area
and radiate to right side of the neck
AR High pitch blowingh early diastolic murmur

Best heard left lower para stenal area (3rd or 4th space )
with patient sitting and leaning forward and breath hold after expiration
VSD
ASD
PDA Loud, continuous 'machinery' murmur , train in tunnel

Pansystolic murmur
heard along the left upper sternal border and outer border of the clavicle.
Write down the difference between pleural rub and pericardial rub?
Pleural rub Pericardial rub
1. It is the cricking sound produced due to 1. It is the sound produced by friction of between
friction between inflamed parietal pleura the two layers of inflamed pericardium.
and visceral pleura.
2. Any where of the chest . 2. Only over the pericardium (better left lower para
sternal ).
3. Absent when respiration is ceased . 3. No relation with respiration .
4. Occur due to pleurisy . 4. Occur due to pericarditis .
CVS 46
In short case u have to face following?
1. Auscultation of a patient with murmur (MS or MR or Mixed)very rare only give if the case is
available
2. In normal patient u have examination following
a. Inspect the precordium
b. Palpate the precordium or locate the apex beat
c. Show me auscultation or show me the murmur
d. show me the thrill
e. as a whole examine the precordium
3. in some case u may to ask examine the peripheral pulse
4. JVP
5. blood pressure
You have to read MS, MR, AS, AR, TOF and

do not go to exam hall with out reading MS and AF
Question about MS?

q. what are the causes of MS ?
Only one & cause is chronic rheumatic hear disease
If sir ask what r else then tell the following three cause otherwise not utter these cause
Three C
Congenital
Calcification
Carcinoid syndrome
What are the complication of MS?

Firs utter the following 4 cause then other s (CASE)
1. Atrial fibrillation (A)
2. Systemic Thrombo-embolism (S)
3. pulmonary edema (E)
4. pulmonary hypertension
5. Right heart failure or CCF (due to pulmonary hypertension ) (C)
if sir want more then say the following
Write down the symptoms of mitral stenosis ?

To remember BEP in CHF
B---Breathlessness
E---Edema
Ppalpitaion
In---
Cchest pain or cough
Hhaemoptysis
F---Fatigue
CVS 47
Examination finding of MS
Pulse Normal
Irregular / pulsus deficit due AF
Bp Normal
Examination of precordium
Inspection Normal or visible apex beat
Palpation Apex not shifted and tapping in nature
Left parasternal heave if RVH
Palpable P2 ----in pulmonary HTN
Auscultation Loud first heart sound (in case of AFheart sound of variable intensity )
Opening snap
Low pitched , localized , rough , rumbling Mid diastoslic murmur , with
pre systolic accentuation
Best heard with bell of stethoscope in left lateral position and breath
hold expiration
What r the sign of P HTN in MS?

Palpation palpable P2
Loud second heart sound
Left parasternal heave (due to RVH)
What is normal diameter of mitral valve ? it is 4-6cm

When will u say severe stenosis and sign of severe stenosis ? < 1 cm
Sign of severity
Pulse is slow volume
1st heart sound soft
MDM prolong
Openic snap closer to 2nd heart sound
ECG patient
AF Chest radiography
Right atrial hypertrophy Congested upper lobe veins.
Double silhouette due to enlarged left atrium.
Straightening of the left border of the heart due to prominent
pulmonary conus and filling of the pulmonary bay by the enlarged
left atrium.
Kerley B lines (horizontal lines in the egions of the costo
phrenic angles).
Uncommonly the left bronchus may be horizontal due to an
enlarged left atrium.
Mottling due to secondary pulmonary haemosiderosis
CVS 48
What is the mechanism of a loud first heart sound?
The loud first heart sound occurs when the valve leaflets are mobile. The valve is open during
diastole and is suddenly slammed shut by ventficular contraction in systole
What does the opening snap indicate?
The opening snap is caused by the opening of the stenosed mitral valve
When it is absent?
It is absent when the valve is diffusely calcified.
What is the mechanism of presystolic accentuation of the murmur?
In sinus rhythm it is due to the atrial systole which increases flow across the stenotic valve from
the left atrium to the left ventricle; this causes accentuation of the loudness of the murmur
in MS apex beat is shifted or not ?
usually not shifted as in MS left ventricle not enlarge only left atrium is enlarge
in MS if u got apex beat shifted then what will you think ?
The patient has ssociated MR
Name the surgical Rx

Valvotomy
Balloon valvuloplasty
Valve replacement
Medical treatment
Asymptomatic patient in sinus rhythm:
Prophylaxis against infective endocarditis tab pen V 250 mg 1+0+ 1
Mild symptoms:
Diuretics ( to reduce left atrial pressure and therefore symptoms.)
Atrial fibrillation:
o (1) rate control (digitalis, beta-blocker or calcium channel blocker);
o (2) Anticoagulants
indication of surgery :
Moderate to severe symptoms or
pulmonary hypertension
a patient of know case of ms suddenly develop unconsciousness with left sided hemi paresis
what is your diagnosis ?
MS with stroke due to thrombo embolism
a patient of know case of ms suddenly develop respiration distress what is your diagnosis ?
MS with acute pulmonary edema due to acute left atrial failure
CVS 49
Heart failure
Pressure Volume overload Muscle
Name of Invisible / Visible /
heart failure HTN stenosed
valve
Right heart Pulmonary PS TR and PR Dilated cardiomyopathy
failure HTN Other volume over load Ischaemic cardiomyopathy
IV fluid
Anemia
Left heart Systemic HTN AS AR & MR
failure
Cardinal feature of right heart failure Cardinal feature of left ventricular failure
Depended edema Tachy cardia or pulsus alternus
Tender hepatomegaly Cyanosis
Raised JVP Gallop rhythm
Bilateral basal creps (+)
Treatment of RVF Treatment of LVF

Bed rest o Bed rest in propped up position
Low flow Oxygen inhalation o High flow Oxygen inhalation
Diuretic o Inj . Lasix 2 amp IV stat and up 8 amp
or 160 mg
o Treatment of the cause
CVS 50
Alimentary system examination
Examination of abdomen proper
Inspection
Palpation
Percussion
Auscultation
Inspection
Following r the step of inspection of abdomen:
1. Stand right side of patient.
2. Introduced your self to the patient and take consent from the patient by telling that I m going
to examination u for my purpose, it will not hurt u. I can proceed.
3. Now expose the patient from nipple to just above the symphysis pubis (ideal nipple to mid
thigh )
4. Now inspected the abdomen in following way
From right side
Look for the following

Size and shape of abdomen
Position of umbilicus
Flanks
Epigastric pulsation
Engorged vein
Body hair distribution
Scar mark
Pigmentation
Striae
Hernial orifice intact / or not
External genitalia
What will u see in size and shape of abdomen?

The abdomen is normally flat or slightly scaphoid and symmetrical
And it moves with respiration
Abnormal size and shape of abdomen is
Shrunken
Distended
Generalized distension
Cause 5 F
F-fat, F-fluid, F-flatus, F-fetus, F feces
Localized distension
We know abdomen is divided in to 9 quadrant on the basis of 2 venticle line (long the
midclavicular line) & two horizontal line one at transpyloric level (at the level of 9th rib ) another is at
level of transtubercular line ( at level posterior tubercle of iliac crest )
51
RHright hypochrondium
E---Epigastrium
LHleft hypochrondium
RFright lumber
LF---left lumber
URumbilical region
RIFright iliac fossa
LIAleft iliac fossa
H Hypogastrium
Caused localized distension or lump / swelling

Right hypochrondium Epigastrium Left Hypochrondium
Enlarge right lobe of liver
Distension of gall bladder Left lobe of liver Spleen
o Mucocele of gall bladder Ca stomach CA of spleenic plexus
o Empyma of gall bladder Ca transverse colon Lymphnode
o CA gall bladder Lymphnode
Hepatic plexus of colon
CA of head of pancrease
Mass in loin
Enlargement of kidney
Hydronephrosis
Renal cell carcinoma
Wilms tumorincase of child
Polycystic kidney
Pyeonephrosis
Mass in the right iliac fossa Hypogastrium Mass in the left iliac fossa
Appendicular lump / abscess In case of male Sigmoid colon cancer

Ilio-caecal TB Palpable urinary bladder Diverticular mass
Ca colon In case of female Impacted stool in
Pregnancy constipated patient
Tubo-ovarian lump Lymphnode
Fibroid uterus
Ovarian tumor
52
Position of the umbilicus
A. Central
B. inverted ---normally present
Or
Everted in ascites and
Incase of everted umbilicus you have to mention the slit
Transverse slit ascites
Or Engorged vein usually seen in sitting
Vertical slit umbilical hernia position but u can see it lying position
Flank
Tell flanks are

Normal
Full ----- is in ascites
Epigastric pulsation
Epigastric pulsation are present or absent
Tell the cause of epigastric pulsation:
1. Aneurysm of abdominal aorta
2. Right ventricular hypertrophy
3. Lean and thin person
4. mass overlying abdominal aorta
5. pulsatile liver
Engorged vein:
If get engorged vein u have to see the direction of that vein
Engorged vein in abdomen is found due to
1. Portal hypertension
2. SVC obstruction (flow down ward)
3. IVC obstruction (flow up ward )
4. Cachexic person (due to loss of subcutaneous fat )
5. Normaly lean & thin person
In abdomen if got engorged vein in three way
Sit Direction of the flow

Above the umbilicus If due to portal hypertension
Direction will be upward
Below the umbilicus If due to portal hypertension

Direction will be downward
Around the umbilicus (caput medusa ) If due to portal hypertension
Away the from the umbilicus
(To remember it In case of portal hypertension ---common formula is away from umbilicus)
53
How will u see the direction of flow :
Place 2 fingers at one end of the vein and apply occlusive pressure
Move 1 finger along the vein, emptying that section of blood in a milking action.
Release the pressure from one finger and watch for flow of blood back into the vein.
Repeat, emptying blood in the other direction.
Note in which direction the blood return quickly ---that direction is the direction of flow for
that patient .
Body hair distribution
It may be normal
Or
Loss of pubic or axillary hair
CLD or
Hypogonadism.
Hypopituitarism
Or increased body hair
In hirsutism or virillism (polycystic kidney, Adrenal hyperplasia)
Pigmentation
Look for
Hypo pigmentation (any fungal infection)
Hyper pigmentation
Cullen's sign:
Discolouration at the umbilicus and surrounding skin
Grey-Turner's sign:
Discolouration at the flanks
Cause
Acute haemorrhagic pancreatitis
Rupture ectropic pregnancy
Rupture spleen
Any cause of bleeding (blood dyscrasia )
Look for striae

These are linear white or pink marks over skin
Due to: stretching of skin cause by rupture elastic fiber
Cause of striae Identifying point
Striae gravidarum In female , below the umbilicus and white , pink
line
Striae of obesity Usually narrow ,whitish , verticle, mostly around
the axilla , groin
Cushing Usually wide , horizontal / oblique pink or purple
color
54
Hernial orifice
Ask the patient to cough and meanwhile u look inguinal canal for hernial horifice intact or not
You also have to look for the following

Movement of Respiration
Thoracoabdominal Normally in female
Phrenic nerve palsy
Abdominal thoracic Normally in male (as male diaphragm > then
female diaphragm )
Gynaecomastia
Spider navi
Also look for any bandage mark and
Palpation:
Superficial palpation
Deep palpation
Organ palpation
Liver
Spleen
Kidney
Urinary bladder
Para aortic lymph node
Fluid thrill
Testes size and consistency
How will you do superficial palpation ?

If examiner told u do superficial palpation only then do it as follow :
1. stand right side
2. Introduced your self to the patient and take consent from the patient by telling that I m going to
examination u for my purpose, it will not hurt u. I can proceed.
3. Now expose the patient from nipple to just above the symphysis pubis (ideal nipple to mid
thigh )
4. Now palpate the abdomen in following way
Step-1 Ask pt if there any pain or not
Step 2 first see temps
Put u r dorsum of the hand first on forehead and then put it on central abdomen to
compare the temperature of abdomen with.
Step -3 with palmer surface of hand and finger just begin to palpate the abdomen which will be
started as anti clock wise in following frequency such as:
LIF---- Left lumber ----left hypochrondium ---Epigastrium ---Right hypochrondiumright
lumberRIF hypogastrium ---end in umbilicus
Use your right hand,

keeping it flat and in contact with the abdominal wall, and finger will be straight
avoid using your finger tips and no movement of MP joint
During palpation u always look at patient's face for any pain and discomfort
SN: if pt tells u that he has pain in LIF then start from left lumber region.
55
What will u see in superficial palpation?
Temperature
Tenderness
Rigidity (if present then mention the site eg. epigastrium)
Hyperesthesia
Any lump
Deep palpation:
Do it with palmer surface of hand and finger in following the sequence of superficial palpation but
here there will be Flexion MP joint and finger will downward pressing the abdominal wall inward .
In deep palpation u also see rebound tenderness if u found tenderness in superficial palpation
If u found any lump in superficial palpation u have to describe it in deep palpation
To remember -----4S CT MRI
S Site (in which quadrant )

S Size (2X 3 cm )
S Shape
S Surface (smooth / irregular )
C Consistency (soft/ firm / hard )
T Tenderness (tender / non tender)
M Mobile (mobile / fixed )
R Relation with under lying
structure & overlying skin
I Intra or extra-abdominal
How will u see the lump is intra-abdominal or extra-abdominal?

Ask the patient to raised his head or leg keeping the knee straight
If the lump becomes prominent ---then it is extra abdominal
If the lump disappear ---then it is intra abdominal
Now how will u describe the lump?

There is an intra-abdominal lump in epigastrium which 2X3 cm, spherical in shape having smooth
surface, non tender, firm in consistency, freely mobile and not fixed with underlying structure or
overlying skin .
How will u see the rebound tenderness?

Press the abdomen with the finger of the hand and keep it for 5 second and suddenly released it and
look pt face and u will see pain or agoni in his face
56
ORGAN PALPATION
According to Hutchison sequence of organ palpation will we left kidney spleen liver right kidney
then urinary bladder.
But we do liver then spleenright & left kidney urinary bladder and para-aortic lymphnode
LIVER PALPATION
In examination if may ask separately to do liver and spleen palpation (with doing inspection or
palpation ) in this case u have do step
1. Stand right side
2. Introduced your self to the patient and take consent from the patient by telling that I m
going to examination u for my purpose, it will not hurt u. I can proceed.
3. Now expose the patient and ask if there any pain present or not
4. ask the patient raised his head to identify the lateral border of Rectus abdominis muscle
5. Now turn the patient head to the left and instruct the patient to take deep breath keeping the
mouth open
6. Place ur palmer surface of the hand keep it flat, and in such a way that the lateral border of
index finger will be parallel to right costal margin as well as tips of finger will not cross the
lateral border of rectus abdominis .
7. Now press the hand inward and forward and keep steady when patient take deep breath and
at the height of inspiration release the inward pressure and keep forward pressure in such
way that your hand will be moved up and down with respiration .
8. Move forward during expiration.
9. if u not find liver go forward until radial border of index finger comes contact with right
costal margin and follow the costal margin up to left mid clavicular line
10. If u find liver is palpable then u have to see the following (see )
a) First follow the margin to see right lobe or left lobe or both lobe is enlarge
b) Measure its length in cm from right costal margin at mid-clavicular line and from xephoid
process
c) Now feel the liver with palmer surface hand and look at face to see tenderness , surface ,
consistency
d) Now percuss on right chest to identify the upper border of liver dullness
Step.1-start percussion on right chest from above to downward until percussion note
become dull .
Step.2-When it become dull keep left finger in that place
Step .3--Now identify the sternal angle (gently rub the right thumb over menubrium
sternum and u feel elevated ridge that is the sternum angle )
Step 4.Now go to the right side u will find the right 2nd rib and below it 2nd
intercostals space and count downward space up to left finger
e) Now measure liver span: From upper border of liver dullness up to palpable lower border of
Liver. Normal 13 cm and if span is > 13 cm then liver is enlarge
f) Hepatic bruit:
See with bell of the stethoscope
57
What will u see in liver palpation:

To remember it --MMS CUT AS
M---Margin Sharp or rounded
Mmeasurement
SSurface Smooth , irregular secondaries ,
C--Consistency Soft , firm , hard
U---upper border of liver
Dull ness
T---tenderness
A---auscultation to hepatic bruit
Sliver span --
U must memorized
Palpation of the liver of this middle cachetic person reveals that the liver is enlarge(say
palpable if span > 13cm ) which is 7cm from right costal margin at mid clavicular line and 5 cm
from Xephoid process non tender , having smooth surface , firm in consistency , sharp margin
,upper border of liver dullness is in 5th intercostals space , liver span is 15 cm and no hepatic
bruit .
58
Now palpation of spleen
In examination if may ask separately to do liver and spleen palpation (with doing inspection or
palpation) in this case u have do step
1. Stand right side
2. Introduced your self to the patient and take consent from the patient by telling that I m
going to examination u for my purpose, it will not hurt u. can I proceed.
3. Now expose the patient and ask if there any pain present or not
4. Now turn the patient head to the left and instruct the patient to take deep breath keeping the
mouth open
5. keep your left hand over left lower thoracic cage to give support
6. Place your right hand on right iliac fossa keeping the direction of tip of the finger toward
10th rib. and palmer surface of the hand keep flat that means whole the hand will touch the
abdomen .
7. Now give down ward and forward pressure during inspiration and go forward during
expiration until your tip of fingers come contact with spleen.
8. during inspiration try feel with spleen
9. If spleen not found then go up to left costal margin
10. If still not found then turn the patient to right lateral position keeping right leg extending
and knee and hip flexion of left leg . Now palpate for the just palpable spleen. Put your
finger just below left costal margin and ask to take deep breath
11. when spleen is palpable then do the following
12. measure it from left costal margin at ant axillary line toward umbilicus or along its long
axis
13. look for notch , feel surface , tenderness , and consistency
14. Try to insert the finger between in costal margin and spleen
15. percussion over the spleen : start at lower left chest and goes to down ward toward the
spleen
16. Next see splenic rubs with the bell of the stethoscope. And try to ballot with both hand .
What u have to in patient with splenomegaly ?
59
Measurement
Margin
Notch
Surface
Consistency
Tenderness
Percussion
Bimanually ballotable
Finger insinuation
Splenic rub
Description of spleen palpation
Palpation of spleen of this middle age person reveals that spleen is moderately enlarge which is 7cm
from left costal margin at ant-axillary line toward the right iliac fossa / umbilicus / along it long
axis ,margin is rounded which is non tender having smooth surface firm inconsistency , percussion
note is dull , spleenic rub is absent , finger insinuation is not possible and not bimanually ballotable
.
Spleen is palpable when it more than twice of it normal length

Enlargement of spleen is
Mild < 4cm,
Moderate 4-8,
Huge > 8 cm or it cross the umbilicus
How will u differentiate between spleen and kidney
Spleen Kidney
1. Finger insinuation Not possible Possible
2. Bimanually palpable Not Yes
3. Percussion Dull Band of resonance due to
overlying colonic gas
4. Direction of Enlargement Toward the umbilicus Downward
5. Move with respiration Early move with respiration Move at the end of respiration
In viva question u will answer first 1 then 2 and then 3 if ask further then said 3& 4 .
60
What do u mean by splenomegaly and hypersplenism ?

Splenomegaly : enlargement of spleen
Hypersplenism : Pancytopenia (reduced WBC , platelet and anemia or reduced RBC ) due to
enlargement of spleen .
next palpate the kidney:

We is palpate by using the both hand
For right kidney
Step one. Place left hand behind the pt back just bellow the costal margin
Step two. Now place right hand over the upper quadrant in such way that tip of the finger not touch
The lateral border of rectus abdominis muscle and lower border of the hand doest not cross
The umbilicus.
Step three: During expiration push your two hands together
Step four: Ask the patient to take deep breath and in inspiration u will feel lower pole of kidney
Moving down ward In between two hands.
Step Five: Now to see balloting push the kidney back & forward with both hands.
Left kidney
Same as right kidney
Now palpate the urinary bladder:

Step 1. Start from the epigastrium
Step 2. Place your both hand in semiprone position and touch tip of finger together like reverse U
Shape
Step 3. Now downward until u palpate or come contact with the upper border of urinary bladder .
Step .4 . when u get the upper border of urinary bladder then percussion from three direction until
dullness appear
One line ---along the mid line from epigastric
Second line along the oblique line from right upper quadrant and
Another oblique line is from left upper quadrant
61
See Paraaortic lymph node;
Step one. Place tips of both fingers vertically first left side of the midline and in between
epigastric and umbilicus and moves all finger like u r massaging manner
Step two: repeat this in right side of mid line
See fluid thrill :

Step one: Place patient hand at mid line of the abdomen at semi prone position keeping slightly
inward pressure .
Step two: Place your left hand flat against left flank.
Step three: Now strike with index or middle finger.
Step four: Feel vibration of wave of water with palmer surface of left hand.
Why patient hand is give at midline?

To prevent transmission of impulse via subcutaneous or skin
When fluid thrill present ?
It present in tens ascites
Next u palpates the testes?

Step one. Take again permission of patient
Step two: feel the testes over the cloths & look for
SIZE:
Small or ---atrophy
normal or
large large orchitis or tumor
Consistency :
Firm Normal
Soft Testicular atrophy
Hardtumor
Pain sensation :
intact painful in during gentle press
painless no pain during gentle press
62
When will u say testicular atrophy?
If the testes have following three criteria then u may call testicular atrophy :
Soft
Small
Pain less
Following r not need in medicine u may learn if sir may ask u
Mac
Rebound tenderness
Murphys signs
Paraaortic lymphnode
stage D
Sifting dullness
To remember it 2 and patch
Step.1: keep the pt in dorsal position

Step 2: Start percussion from epiastric region along the mid line up to umbilicus
Step 3: As soon as u reach the umbilicus then do percussion to the right sided or left side as u want
Until dullness appear (if u dont get dullness stop just before the lateral border of muscle)
Step 4: Turn the patient in left lateral position keep at least 20 second (in Macleods 10 seconds)
Step 5: Then percussion down ward toward left until dullness reappear .
Step 6: Again turn to right and percussion downward until dullness reappear
63
What do u mean Divarication of the recti ?

In ascetic patient when pt will elevate their head then u will see longitudinal midline bulging this is
due to sparation of twin rectus abdominis muscles laterally on contraction causing the underlying
organs to bulge through the resultant mid-line gap.
AUSCULTATION:
What we see in auscultation

Bowel sound
Renal bruit
Hepatic bruit if liver palpable
Splenic rub
Venus hum
Bowel sound :
Usually listen right side of umbilicus (just above macberneys point )
Interpretation
Bowel sound: present --
Bowel sound: absent (before telling absent bowel u have to
listen for 3 mins)
Cause of bowel sound absent is
Paralytic ileus
Peritonitis
Renal bruit
Where u listen it
Place the stethoscope 2-3 cm above and lateral to the umbilicus
Cause: renal artery stenosis
Hepatic bruit and splenic rub
Listen only when u when u get enlarge liver or spleen with bell of stethoscope
Cause: of liver bruit
Hepatoma or
Acute alcoholic hepatitis.
Venous hum
Listen in between xephoid process and umbilicus
64
Palpation Incase of ascites patient:

In ascites u have to palpate in dipping method
Incase of liver:
U can do it single or both hand
Step1. Consent, exposure and respiration is like that of normal palpation
Step .2 here hand will placed flat in right iliac fossa and direction of tip of right fingers toward
the Right costal margin
Step-3 During expiration give 2 push downward and forward and during inspiration keep the hand
o steady & try to feel the organ
1st push is to remove the fluid and
2nd push is to palpate the organ
Step -4 continue until find liver or reach to costal cartilage
In case of spleen
Do it in single hand
Step1. Consent, exposure and respiration is like that of normal palpation
Step. 2. keep your left hand over left lower thoracic cage to give support
Step 3. Place your right hand on right iliac fossa keeping the direction of tip of the finger
Toward 10th rib.
Step 4. like liver palpation give 2 push down and forward and go toward left costal margin until
Spleen is palpable .
Now in examination u have face GIT in following way:

o Sir may ask inspect the abdomen tell ur finding
o Sir may ask u palpate the abdomen tell ur finding
o Palpate the liver or spleen
o See the sifting dullness
o Palpate the liver and spleen in ascites patient (sir want u do it in Deeping method or not)
65
CAUSE of HEPATOMEGALY:
Tender hepatomegaly Non tender hepatomegaly

o Viral hepatitis o Secondary in the liver
o Liver abscess o Kala-azar
o HCC o Malaria
o Congestive cardiac failure o Lymphoma
o Leukemia
o Myelofibrosis
o Polycythemia
Cause of splenomegaly
Common cause
Haematological disorders KamaL-3 my Thal
Lymphoma Ka-Kala-azar
Leukaemia especially chronic myeloid Ma-Malaria
leukaemia Lchronic liver disease with portal HTN
Myelofibrosis Llymphoma
Polycythaemia Lluekemia (CML)
Haemolytic anaemia MYMylofibrosis
ThaThalassaemia
CLD Portal hypertension
Infections What are causes of just palpable spleen?
Enteric fever
Glandular fever
Malaria
Malaria
Brucellosis Subacute bacterial endocarditis
Kala azar (leishmaniasis) SLE
Subacute bacterial endocarditis Other cause of spelnomegaly
Enteric fever o Lymphoma
o Leukemia
Rheumatological conditions o CLD with Portal HTN
Rheumatoid arthritis (Felty's syndrome)
o Disseminated TB
Systemic lupus erythematosus
Rarities
Sarcoidosis
Amyloidosis
Glycogen storage disorders
66
What are the cause common hepato-splenmegaly :

KamaL-3 my Thal
Ka-Kala-azar
Ma-Malaria
Lchronic liver disease with portal HTN
Llymphoma
Lluekemia (CML)
MYMylofibrosis
o Lymphoma
o leukaemia
o Dessiminated TB
ThaThalassaemia
Exudative cause
Infection
Tuberculosis Common causes
Spontaneous bacterial Peritonitis o Malignant disease
Malignancy Hepatic
Budd-Chiari syndrome Peritoneal
hepatic venous obstruction o Cardiac failure
Pancreatitis o Hepatic cirrhosis
Lymphatic obstruction
Spontaneous bacterial peritonitis
Hypothyroidism
Transudative
Nephrotic syndrome
CLD
CCF
Meigs' syndrome
Hypoproteinaemia
Malnutrition @ Fever with ascites
Protein-losing enteropathy o Abdominal TB
o Lymphoma
o leukaemia
A patient with hepatomegaly with ascitis
CCF
Hepatoma with secondary in the peritoneum
Lymphoma Fever with splenomegaly
Dessiminated TB o Kala-azar
Chirrohsis of liver with portal HTN o Malaria
o Enteric fever
Trasnsudative cause o SBE
A patient with splenomegaly with ascits o Lymphoma
o CLD o leukaemia
o Lymphoma
o Dessiminated TB
o leukaemia
o Dessiminated TB
67
SHORT CASE------one ----- HEPATOMEGALY
A patient with hepatomegaly only (secondary in liver) may give u in short case
The Question will be palpate the liver and tell ur finding?
Palpate the liver in appropriate procedure

U describe ur finding in following way
Palpation of the liver of this middle cachetic person reveals that the liver is enlarge(say
palpable if span > 13cm ) which is 7cm from right costal margin at mid clavicular line and 5 cm
from Xephoid process non tender , having irregular surface , firm to hard or hard in
consistency , sharp margin ,upper border of liver dullness is in 5th intercostals space , liver span
is 15 cm and no hepatic bruit .
Q examiner may ask u Pl palpate the abdomen?

Then u have to do all step of palpation
Then describe it as follow
In superficial and deep palpation of abdomen of this middle age cachetic patient reveal that the
patient temperature of abdomen is normal, no tenderness, hyperesthesia, rigidity.
Organ palpation reveals that the liver is enlarge(say palpable if span > 13cm ) which is 7cm from
right costal margin at mid clavicular line and 5 cm from Xephoid process non tender , having
irregular surface , firm to hard or hard in consistency , sharp margin ,upper border of liver dullness is
in 5th intercostals space , liver span is 15 cm and no hepatic bruit .
Spleen and kidneys are not palpable, no fluid thrill and testis is normal in size and consistency
What is ur diagnosis? If the examiner only tells u palpate the liver then
I have some differential diagnosis in my mind Only palpate the liver and tell the finding
For this (see the boX)I want to do some relevant If he want to know the Dx then ask sir that u
Such as want to palpate the spleen want to see relevant like palpate the spleen and
sifting dullness ,testicular atrophy pulse that
others mention in left sided box
I want see in general examination
Anemia lymphoma, leukemia , kala-azar
Jaundice If non tender
Temperature infective cause kala-azar , Secondaries in the liver
lymphoma,leukaemia Other cause of hepatosplenomegly
Lymph node Not tell if u have not find spleen
Boney tender ness Lymphoma
JVP Leukemia
Stigmata of CLD Early stage of CLD
Jaundice CLD If tender than
Hepatic faces Viral hepatitis
Spider naevi CCF
Gynaecomascia Liver abscess
Oedema Primary hepatocellular carcinoma
Palmer erythema
Leukonychia
68
What is ur diagnosis? Why?
My diagnosis is secondary metastasis in the liver
Because liver is hard, non tender and irregular surface having multiple nodules
Why not primary?
In Primary hepatocellular carcinoma liver is tender and single nodule.

In primary HCC carcinoma is usually associated with CLD.
Thats why if it is primary HCC then we will get splenomegaly and other stigmata of CLD which
are absent in this patient.
Why this is not a case of CCF?
In CCF the liver is soft with raised JVP & tender hepatomegly and depend edema
With or with out Left parasternal heave and P2 and function TR
It may be lymphoma or leukemia?

If it is lymphoma or leukemia then it is usually associated with splenomegaly and fever
In case of lymphoma other lymphoadenopathy usually present.
In case of leukemia pt is usually toxic and boney tender ness present
What it is not a kala azar or malaria?

In kala-azar sole hepatomegaly is unlikely and it is usually associated with splenomegaly and spleen is
enlarge before the liver palpable
How will u differentiate from primary HCC from 2nd HCC
HCC 2nd in the liver

Tenderness Tender hepatomegaly Non tender hepatomegaly
Number Single lesion Multiple lesion
Umbilication Present Absent
Bruit Present Absent
Bio chemical marker Alpha feto protein + (60%) CEA +
nd
Clinically how how will u differentiate between HCC @ 2 in liver?
Primary case sing of hepatic insufficiency present such as ascites, splenmegaly , spider , jaundice
Palmer erythema , leuconychia , gynaecomastia testicular atrophy
Patient is more toxic in primary case & it is more pain ful
Secondary only hepatomegaly which hard and non tender , left supraclavicular gland
Plus ---see the difference between HCC @ 2ndaries in the liver
What may the primary site?

To remember PUBLIC-T
C-Colon, I-intestine-- gastric, P--prostate and pancreas, B--breast and T--thyroid , L--Lung , U
uterus
69
What investigation you want?
To see the liver status
Liver function test SGPT, S. Billirubin , prothrombine time
Renal function test S.creatinin
To establish diagnosis
USG of whole abdomen
USG guided FNAC from liver
To find out the primary site
CXA PA
Endoscopy of upper GIT
Colonoscopy
Marker
Alpha feto protein and CEA
What is the treatment of secondary HCC?

Rx is chemotherapy
What is the treatment of primary HCC?

Treatment:
Hepatic resection
Liver transplantation
Percutaneous ablation
o Ethanol injection
o Radiofrequency ablation
Chemoembolisation
o Adriamycin and gelfoam
70
Short CASE ----TWO ------ HEPAT-SPLENOMEGALY
A patient with hepat-splenomegaly
This patient may have
o Hemolytic anemia
o Kala-azar
o CLD
o Lymphoma or luekaemia(CML)
In short case what ever patient diagnosis u will told ur diagnosis on basis of examination finding as u
cannot ask history
Q. palpates the abdomen?
First do superficial and deep palpation then goes liver and spleen palpation ?
What is ur finding ?
In superficial and deep palpation of abdomen of this middle age patient reveal that the patient
temperature of abdomen is normal, no tenderness, hyperesthesia, rigidity.
Organ palpation reveals that the liver is enlarge(say palpable if span > 13cm ) which is 7cm from
right costal margin at mid clavicular line and 5 cm from Xephoid process non tender , having smooth
surface , firm in consistency , sharp margin ,upper border of liver dullness is in 5th intercostals space ,
liver span is 15 cm and no hepatic bruit.
from left costal margin at ant-axillary line toward the right iliac fossa / umbilicus / along it long axis
,margin is rounded which is non tender having smooth surface firm inconsistency , percussion note is
dull , spleenic rub is absent , finger insinuation is not possible and not bimanually ballotable
Fluid thrill absent and testis is normal in size and consistency.
Cause of hepatosplenomegaly
What is ur diagnosis? . KamaL-3 my thal
I have some differential diagnosis and for these region (these are in Ka-Kala-azar
Box )I want to do some relevant Ma-malaria
Such as: L1-CLD with portal HTN
In general examination; L2-lymphoma
Appearance Hemolytic faces thalassaemia L3---leukemia
Hepatic faces --CLD Incase of child
Thal--Hemolytic anemia
Anemia Kala-azar, lymphoma , leukemia and Old age
Thalassaemia My--Mylofibrosis
Chronic myeloid leukemia
Jaundice CLD , lymphoma and thalassaemia
Lymph node Lymphadenopathy lymphoma , CLL At least if examiner asked what else
Temp ---increased Kala-azar and then say disseminate TB
Boney tenderness Leukemia
Look for stigmata of CLD
Palmer erythema Spider naevi Gynaecomastia
Engorged vein Ascites Testicular atrophy
71
Tell this differential diagnosis which appropriate Point favor of ur diagnosis are
according the clinical finding
Hemolytic anemia Pt is usually young

Hemolytic face depressed nasal bone,malar
Prominence
Severe anemia and mild jaundice
Hepato-splenomegaly
Blackish skin hemochromatosis
CLD Stigmata of CLD
Hepatic faces
Jaundice
Palmer erythema
Spider naevi
Gynaecomastia
Engorged vein
Ascites
Testicular atrophy
Hepato-splenomegaly
Kala-azar Endemic zoon whole mymensingh .
Anemia
Temperature / HO fever
Hepatolmegaly
Lymphoma Anemia / jaundice
Generalized lymphadenopathy
Hepato-splenomgal
Fever and wt loss
Leukemia Anemia
Patent toxic
Boney tenderness
Lymphadenopathy + / -
Hepato-splenomegaly
If the patient is old age
Chronic myeloid leukemia Anemia
Hepato splenomegaly
Myelofibrosis Anemia
Hepato splenomegaly
What is u diagnosis & what r point in favor Dx?

Suppose it is a case thalassaemia u will u tell the point from the box
Next question will be why not it is a case of CLD or
Lymphoma
Kala-azar
U tell the examiners that I do not got these point (see the box) in favor CLD , Lymphoma, Kala-azar?
72
Short case NO:::::::::THREE::::::: SPLENOMEGALY
A patient with only splenomegaly ?
It may be just palpable / mild < 4 cm
Or
Moderate to huge splenomegaly > 4 ---8
A patient with huge splenomegaly ?
Palpate the spleen follow the appropriate sequence
Tell u finding as follow :
,margin is rounded which is non tender having smooth surface firm inconsistency ,there is a notch in
its upper border, percussion note is dull , spleenic rub is absent , finger insinuation is not possible and
not bimanually ballotable
What is ur diagnosis?
I have some differential diagnosis and for these region (these are in Box) I want to do some relevant
What r the differential diagnosis What will be the CBC and PBF picture of CML?
Cause of hepatosplenomegaly In TC- >100000 (100000600000)
KamaL-3 my thal In DC> immature cell of myeloid series
Ka-Kala-azar Meta meylocyte
Ma-malaria Myelocyte
L1-CLD with portal HTN When will u tell it acute leukemia?
L2-lymphoma If blast cell > 70 %
L3---leukemia What are phase of CML
Incase of child A --Accelerate
Thal--Hemolytic anemia BBlast crisis
Old age Cchronic phase
MyMyelo fibrosis What is Philadelphia (Ph) chromosome. ?
Chronic myeloid leukemia This is a shortened chromosome 22 and is the result of a
At least if examiner asked what else then say reciprocal translocation of material with chromosome 9.
Disseminate TB Is presence of Ph chromosome bad or good ?
What relevant u wants to see? Presence Ph chromosome is good as it respond to therapy
In general examination;
Appearance Hemolytic faces thalassaemia How ph chromosome act ?
Hepatic faces --CLD The break on chromosome 22 occurs
in the breakpoint cluster region
Anemia Kala-azar, lymphoma , leukemia and (BCR). The fragment from
Thalassaemia chromosome 9 that joins the BCR
Jaundice CLD , lymphoma and thalassaemia carries the abl oncogene, which
forms a chimeric gene with the
Lymph node Lymphadenopathy lymphoma , CLL remains of the BCR. This BCR ABL
Temp ---increased Kala-azar and increase tyrosine kinase activity,
Boney tenderness Leukemia which plays a causative role incellular
proliferation, differentiation and
Look for stigmata of CLD
survival
Palmer erythema Spider naevi Gynaecomastia
Engorged vein Ascites Testicular atrophy
73
Why this is not kidney?
It is not kidney because
Finger insinuation is not possible
Not Ballotable with both hand
Percussion note is dull (in kidney band of resonance due to colonic gass)
Move early with respiration and inlarge toward the right iliac fossa
Why this is hemolytic anemia ? Why this is not hemolytic anemia ?
My diagnosis is hemolytic anemia : Patient have only hepatosplenomegaly but Not
Pt is usually young have the others feature of hemolytic anemia :
Hemolytic face Depressed nasal bone, malar Hemolytic face Depressed nasal bone, malar
prominence , frontal bossing prominence , frontal bossing
Severe anemia and mild jaundice Severe anemia and mild jaundice
Hepato-splenomegaly Blackish skin hemochromatosis
Blackish skin hemochromatosis
Why this a CLD? or Why this not a case of CLD?

This is CLD with portal HTN because patient Patient have only hepatosplenomegaly but no HO
have of stigmata of CLD
Stigmata of CLD(tell only those u get in this pt ) Hepatic faces
Hepatic faces Jaundice
Jaundice Palmer erythema
Palmer erythema Spider naevi
Spider naevi Gynaecomastia
Gynaecomastia Engorged vein
Engorged vein Ascites
Ascites Testicular atrophy
Testicular atrophy
Hepato-splenomegaly
Why u is a case of kala azar Why not kala-azar?

Because the patient has the following Only hepatosplenomegaly
Endemic zone (mymensingh ) Have not
Anemia Anemia
Temperature / fever Temperature / fever
Hepatosplenomegaly Not come from endemic zone
Lymphoma because the pt have Not lymphoma

Anemia / jaundice as the patient have only Hepato-splenomgal
Generalized lymphadenopathy not have
Hepato-splenomgaly Anemia / jaundice
Fever and wt loss Generalized lymphadenopathy
Fever and wt loss
74
Why this not a case of leukemia Why this not a case of leukemia
This is a case of leukemia because the pt have This is not a case of leukemia because the pt have
Anemia only slplenomegaly but
Patent toxic Anemia
Boney tenderness Patent toxic
Lymphadenopathy + / - Boney tenderness
Hepato-splenomegaly Lymphadenopathy + / -
If patient is old then tell examiner that

May be a case of CML or mylofibrosis
Anemia and massive splenomegaly
If the pt is child and boney tenderness is present
then diagnosis will be ---ALL
If the patient is adult and boney tenderness is
present then diagnosis will be AML
If examiner want to know what else may be cause ?

Then u say it may be a case of disseminated TB
Short case::::::::FOUR:::::::JUST/ MILD SPLENOMEGALY

Some times u may give mild splenomegaly / just palpable
,margin is rounded which is non tender having smooth surface firm inconsistency , percussion note is
dull , spleenic rub is absent , finger insinuation is not possible and not bimanually ballotable
What is diagnosis?
What are causes of just palpable spleen?
I have some differential diagnosis in mind that why &
Enteric fever
I want to see some relevant
Such as Malaria
Subacute bacterial endocarditis
First tell the box of huge splenomegaly SLE
F o r SBE Clubbing ,splinter Other cause of spelnomegaly
haemorrhage , murmur o Lymphoma
Enteric fever / malaria Temp. o Leukemia
SLE / connective tissue Joint swell & tenderness o CLD with Portal HTN
disease Rash & female patient o Disseminated TB
75
SHORT CASE :::::five:::::: ASCITES :::::::::
In u r exam there u may a short case find a short case of ascites :Such as
Ascites due to CLD with portal HTN
Ascites due to TB
Ascites due to intra abdominal malignancy
Rarely u in NS patient sir ask do exam of ascites
What ever the diagnosis of the pt u have to examine the patient according to procedure and tell the
diagnosis on the basis of ur clinical finding not on what written in the file of the pt in which it was
diagnosed on basis of investigation
Q Inspect the abdomen and what u r finding? (Only inspect)

Q Palpates the abdomen and tell u r finding? (Super &deep palp. and palp in dipping method)
Q. See fluid thrill and shifting dullness?
Q. Examine the abdomen of this patient? (inspection to auscultation )
If u r asked to see only inspection n& u find engorged vein than after inspectin ask sir that I want to see
the direction of flow that why I want to sit the patient and If u r allowed then examine the flow of the
engorged vein .
NEVER FORGET TO PALPATE IN DIPPING METHOD IN ASCITES PATIENT
Now tell sir ur finding
Inspection / examination of abdomen of this middle age person reveals that abdomen is hugely
distended, umbilicus is central, everted having transvers slit, flanks are full. There are some
engorged veins, flow of which is upward. No visible peristalsis, no pigmentation, no striae and
hernia orifice is intact.
Superficial and deep palpation reveals normal temperature and no rigidity, hyperesthesia,
tenderness and intra or extra abdominal lump.
Liver and spleen cannot delineated as to huge ascites .
And testis in normal size and shape (or testes are atrophied / testicular atrophy present )
Fluid thrill present and shifting dullness present
Bowel sound present and renal bruit absent
What is u r finding ? The differential diagnosis

The patient have ascites CLD with portal HTN
Abdominal TB
What is ur diagnosis? Intra abdominal malignancy
I have some differential diagnosis in my mind and for CCF
This I want to do some relevant examination of this pt
NS
What relevant u want to
For CLD see Stigmata of CLD For CCF
Hepatic faces Palmer erythema Raised JVP Murmur

Jaundice Leukonychia Tender Left para sternal
Spider naevi Oedema hepatomegaly heave
Gynaecomascia Depended edema Apex beat shifted
Loss of body and Lung crep +/-
pubic hair Ronchi / vesicular
breath sound
prolong expiration
76
Abdominal TB Intra abdominal malignancy with peritoneal

shidling
Low grade Fever Verchows gland (left supraclavicular LN)
Weight loss / cachexic Or other lymphadenopathy
Doughy feeling Alteration of bowel habit
Auscultation of lung
Now what is u r diagnosis?

My diagnosis is decompensate CLD with portal hyper tension
What r the point I favor u r diagnosis?
Because I have got following stigmata of CLD in patient (u will tell what u got from the box) such as
Hepatic faces ,Jaundice, Spider naevi, Gynaecomascia ,Loss of body and pubic hair, Palmer
erythema , Leukonychia , Oedema and engored vein
Why u told that it is Decompensated CLD?

As because ascites and jaundice are the sign of decompensation
(Sign of decompen-jaundice, ascites, and encephalopathy)
Spleen is not palpable but why u told CLD with portal HTN?
Spleen may not palpable due to huge ascites and spleen is only palpable when it becomes twice of his
normal length . so spleen may enlarge which may not be palpable
Other sign of portal hypertension are:
Ascites and engorged vein on abdomen with up ward direction
That why we called it decompensates CLD with portal HTN
Box -a Box- b
What are sign of hepatic insufficiency? What are the signs of portal hypertension?
Hepatic faces (sunken eye, Malar prominent) To remember it keep mind SEA
Jaundice SSlepnomegaly
Flapping tremor EEngorged vein
Gynaecomastia Abdomen
In case of female breast atrophy Above umbilicus direction of flow
Spider nevi upward
Below umbilicus direction of flow down
Loss of body and pubic hair
ward
In hand
Caput medusa arround the umbilicus,
o leukonychia.
direction of flow away from the
o Dupuytren's contracture
umbilicus
o Palmar erythema
Esophageal varices
Testicular atrophy Clinically haematomesis and malaena
When will u called the testes are atrophied? Via upper GIT endoscopy
If the testes are soft, small and loss of pain AAscites
sensation. Other Fetor hepaticus ,Hepatic encephalopathy
77
If u got a spider nevi following question may be What is gynaecomastia?

asked ? Enlargement of male breast tissue due to
o Spider telangiectasia is a central arteriole from proliferation of glandular component:
which small vessels radiate.
o Site : usually found only above the nipples How will u see gynaecomastia?
along the area of superior venacava First u sees with palm of the hand only gently
distribution rubbing over the breast.
o Normally found: 1or 2 in 2 % people Then try feel the glandular tissue of breast
o Cause due to: hyper dynamic circulation . in simply squeezing breast with pulp of the
case of CLD due to access oestrogen as fingers
metabolism of oestrogen decreased by
diseased liver. What r the Causes of gynaecomastia ?
Other cause pregnancy , viral hepatitis ,OCP , To remember --- BLAST3
thrytoxicosis , BBronchogenic carcinoma
o How will u see it Lchronic liver disease
With the help of pin head or glass slide . ask AAdrenal carcinoma
the patient to sit down and see above the Sspirolactone
nipple front and back and also both upper limb T1--Testicular tumour (leydig cell),
o How will differentiate between purpura T2-- Testicular failure (trauma, orchitis, radiation)
and spider nevi T3---Thrytoxicosis
o Purpura does not blanch on pressure What is the mechanism of gynaecomastia
(as it extravascular ) Mechanism: Either due to increase activity of
Spider nevi : Blanch on pressure and when oestrogen or decrease activity of testosterone
release the pressure it will reappear
Name some drug responsible gynaecomastia
Spirolactone , cemitidine , digoxin
Cause of gynaecomastia is in CLD ?

Due CLD it self @ drugs spirolactone
Painful gynaecomastia found in :
Spirolactone
Why this not CCF?

The patient have only Generalized edema with ascites
Cardinal feature of CCF is absent:
JVP not raised
No tender hepatomegaly
Other feature of Right ventricular hypertrophy such
Left para sternal heave
TR
Sign of Pulmonary HTN
Palpable P2
Other murmur
Lung crep ++
Vesicular breath sound with prolong expiration.
78
If the patient have only ascites with out generalized edema:
Think for abdominal TB
Abdominal malignancy with peritoneal sidling
In case of abdominal TB:
History of long standing low grade fever
Weight loss
Doughy feeling
HO recurrent sub. acute obstruction
Alteration bowel habit
In case abdominal malignancy with peritoneal sidling
If u exclude CLD and CCF first
Then TB exclude
Then think malignancy
See
Virchows gland
Lymphoadenopathy
Alteration of bowel habit
What investigation u want to do in case of ascites
For CLD To exclude TB
Liver function test CBC ESRhigh
SGPT------N / MT
S.Bilirubin --- N / CXR
Prothrombin time N / Ascetic fluid study
s.ablumin---- Biochemical Cytological , micro biological
AG ratio---- alter What are new investigation of ascetic fluid for
Viral marker TB :
HBs Ag o ADA
Anti-HBc Ig G o C125
Anti-HCV Name the investigation for ascites due to
Urine RME --- No Proteinuria or no RBC abdominal malignancy
S.creatinin o Ascitic fluid malignant cell
Imaging o USG of whole abdomen
USG of HBS and pancreases o CT scan
coarse echo structure, Splenomegaly, ascites o Diagnostic Laparoscopy and laparotomy
Ascitic fluid study
Transudative and SAAG > 1 .1 CLD
Exudative ---incase of TB & Malignancy
Color of fluid
o Serous CLD
o Straw TB
o Haemorrhagic malignancy
Endoscopy of Upper GIT
To see the varices
FOR DETAILED SEE QUESTION PART OF LONG CASE OF CLD ,

KALA-AZAR , THALASSEMIA , LYMPHOMA
SHORT CASE :::::::SIXNORMA L ABDOMEN :::::::
79
Cranial nerve examination
Two pairs of cranial nerve they some are pure sensory (128) , motor (346,11,12) rest are mixed
Name Type Location
I. Olfactory nerve Sensory
CEREBRAL CORTEX
II. Optic nerve Sensory
III. Oculomotor Motor
MID BRAIN
IV. Trochlear Motor
V. Trigeminal Mixed
VI. Abducens Motor
PONS
VII. Facial Mixed
VIII. Vestibulocochlear Sensory
IX. Glossopharyngeal Mixed
X. Vagus Mixed
MEDULLA
XI. Accessory Motor
XII. Hypoglossal Motor
Examine the cranial nerve

OLFACTORY NERVE
Receptor in the mucous membrane of the nose the nerve run bellow the frontal lobe and end in the
uncus of the ipsilateral temporal lobe.
How to examine the olfactory nerve
1. Check that the nasal passages are clear. With torch

2. Ask the patient to close his eyes and shut one nostril with a
finger
3. Present commonly available odours such as coffee, chocolate,
soap or orange
4. ask the patient to sniff
5. then do the same procedure in opposite nostril
Interpretation
Anosmia : loss of the sense of smell
Cause:
Head injury,
local compression or invasion by cancer (meningioma)
Parosmia : Perversion of the sense of smell that is when pleasant odours are perceived as unpleasant.
. Cause
after head trauma,
sinus infection
side-effect of drugs
Olfactory hallucinations are a feature of complex partial seizures of temporal lobe
80
Optic nerve:
Here u has to know anatomy and physiology to do test for optic nerve
Eye ball
Retina
Rodnight vision
Cone-color vison Optic nerve
The nasal half of the retinal Optic chiasm

receives input from the
temporal part of the visual Optic tract
field in each eye,
The temporal half of the Lateral geniculate body
retinal receives input from the
nasal half of the eye. Optic radiation .upper fiber
in parietal lobe
Optic radiation lower fiber
in temporal lobe
Occipital cortex
1. Total loss of vision in one eye(lt) because of a lesion of the optic nerve
2. Bitemporal hemianopia due to lesion of the optic chiasm
3. Right homonymous hemianopia from a lesion of the optic tract
4. Upper right quadrantanopia from a lesion of the lower fibres of the optic
radiation in the temporal lobe.
5. lower right quadrantanopia occurs from a lesion of the upper fibres of the
optic radiation in the ant. Apart of the parietal lobe
6. Right homonymous hemianopia with sparing of the macula due to lesion

of the optic radiation in the posterior part of the parietal lobe
81
Now u has to learn about light reflex
Afferent path way read Efferent pathway read

Above to downward bellow to up ward
Retina Constrictor pupil
Optic nerve Short cilliary N
Chiasm
Optic tract Cilliary ganglia
Just before geniculate III nerve

body it leave the tract
n goes to superior
coliculus of mid brain
Some goes to mid Edinger westphal N.

brain end in EW N
some cross the mid Mid brain
line and goes to
opposite Ew nucleus
Light Reflexes:
When light fall in cornea of on eye then it causes constriction of pupils of both eye this is the light
reflexes.
Q Classify light reflexes?

Light reflexes is two type
Direct reflex (when u give light on right and their will constriction of right eye )
Indirect reflexes (when u give light on right and their will be constriction of left eye )
Interestingly both this occur simultaneously
What is Afferent, Efferent and centre of light reflexes ?
Afferent centre Efferent

III nerve (oculomotor ) Mid brain (edinger westphal N.) II nerve (optic )
What r the muscle of pupil and their nerve supply and action ?
Muscle of pupil Nerve supply Action This action called

Sphincter pupillae III (para sympathetic ) Constriction of pupil Miosis
Dilator pupillae Sympathetic nerve Dilatation of pupil Mydriasis
82
Examination of optic nerve
U have to see the following:
Visual acuity
Color of vision
Field of vision
Papillary reflexes
Opthalmoscopy / Fundoscopy
VISUAL ACUITY
Ideally seen with the snellens chart Ideally seen with the snellens chart
But we have not snellens chart and we
will see it like below (depend on pt
educational back ground)
Two type of vision
Distal vision
Near vision
Distal vision
Ask the patient to
Look at the clock tell the time
Tell bed number of the bed near
the door
Near vision
Ask the patient to read the news paper
or book
d/D , d= distance of patient from the chart
D= distance in metres at which the patient is expected to
Read letters.
Suppose any pt visual acuity is 6/ 12
Pt can see the line from 6 meter distances that one can see
normally from 12 metres distance .
COLOR OF VISION
Usually seen with Ishihara chart
We see here with 3 colors
o Red
o Blue
o Green
Take three pens of these color and hold pen one after another
Ask the patient to identify these color
Colour vision is mainly confined to the macular field

;Acquired abnormalities in colour vision are therefore a sensitive test for optic neuritis
83
Field of vision
Usually see with the perimetry
1. patient and examinee should sit down 1 meters

apart and at same level
2. Close opposite eye of the both person with their
hand ( eg. Patient right eye remained closed
with pt right hand & examinees left eye
remained closed by his left hand )
3. Now tell the pt to look at only on your right
eye .
4. now keep index finger in between u and pt
5. Now Stretch your right arm out and up so that
your hand is just outside your field of vision, an
equal distance between you and the patient
6. Slowly bring you index finger into the centre
(perhaps wiggling ) and ask the patient to notice u
as soon as they can see it (it better to bring it
obliquely )
7. You should both be able to see your hand at the
same time.
8. Test upper right and left, lower right and left
individually, bringing your hand in from each
corner of vision at a time. it will make an
imaginary X keeping eye in central .
9. Ensure that the patient remains looking directly at
you (many will attempt to turn)
10. Map out any areas of visual loss in detail, finding
borders.
11. Now do this examination other eye
To see central scotoma
Use a red headed hat pin

Move it from temporal to nasal side in
mid line
Ask the patient do you see it?
Tell me when it will disappear
84
Papillary reflexes
Direct reflex and
Indirect or consensual
DIRECT REFLEX
1. Examine the pupils for shape and symmetry,

2. Taking account of ambient lighting.
3. Ask the patient to fix the eyes on a distant point
straight ahead.
4. Bring a bright torchlight from the side to shine
on the pupil.
5. Look for constriction of the pupil shone on
(direct light reflex) and
INDIRECT or CONSENSUAL
1-3. Do step one to three as same direct
reflex
4. Here some body prefer to give hand in
front of nose
5. Bring a bright torchlight from the side to
shine on the pupil.
6. this time look For constriction of the
opposite pupil (consensual light reflex).
Accommodation reflex
1. Ask the patient to look at a distant point
2. Now bring your index finger in front of the
patient eye
3. distance of the finger from eye not less 15 cm
or 6 inch
4. Now ask the patient to focus on it
5. Now look at patient eye for
There will be convergence of the eye ball

&
Bilateral Constriction of the pupil
In curvature of the lens due to
ciliarymuscle contraction which can not
see
NEXT DO FUNDOSCOPY :
( Not for the MBBS student) just mention the name what u can see with it
We can see retinal artery , vein , disc , hemorrhage ( dot, blot , flame), exudates (hard / soft)
DM and HTN retinopathy / papillaedema
85
Examine or describe normal pupil is ___to remember _PERRLA
P---Pupil is
Eequal
Rrounded
Rreaction to
L light and
Aaccommodation present
Name Figure
Anisocoria- unequal pupils.
Mydriasis- refers to the dilation of the pupils.
Miosis- refers to the constriction of the pupils
Cause of Miosis- ? Q cause of mydriasis ? Q cause fo Anisocoria-

unequal pupils.
Horners syndrome Optic nerve lesion Physiological
AR pupil 3rd nerve palsy Iritis
Poisoning OPC , opium (morphine) Holmes adie pupil Holmes adie pupil
Drugs Pilocarpine , physostigmine Atropine Syphilis
Pontine haemorrhage (pin point) Datura poinsoning CVAHerniation
What is argyl l-robertson pupil?
It is small, unequal irregular shape pupil which

do not react to light and react to accommodation
Cause
Neurosyphilis
Diabetes mellitus
86
See the ocular movement
Eye ball is supplied by 6 muscle

4 recti and 2 oblique
All are supplied by 3 rd nerve except
lateral rectus 6 th nerve superior
oblique by 4 th nerve
To remember SO4 LR-6
SRupward movement SOupward movement

in abducted eye in adducted eye
LRabduction of eye or MRadduction of eye or

lateral movement medial movement
IRdown ward IOdown ward

movement in abducted eye movement in adducted eye
Test for ocular movement
1. Sit down if possible like confrontation test

2. Now instruct the patient to move his eye along
the movement of the your finger but head
should be fixed during eye movement
3. Ask the patient to tell u if he notice any diplopia
4. Before starting examination carefully look for
ptosis , unequal pupil , convergence or
divergence squint
5. Now keep your index finger in between patient
and u .
6. Now move the finger like
7. Also look for nystagmus
H figure
& diplopia and
any movement disorder
87
88
CRANIAL NERVE V: TRIGEMINAL
It is a mixed having both sensory and motor

Sensory: facial sensation in 3 branches-
Ophthalmic (V1),
Maxillary (V2),
Mandibular (V3).
Motor: muscles of mastication.
Name of Nucleus Function site
Mesencephalic nucleus Proprioception Mid brain
Main sensory nucleus Light touch Pons
Nucleus of descending Pain and temperature
Trigeminal tract
Motor nucleus Motor movement Pons
So examination of trigeminal consist of

Motor & Sensory
In motor
Inspection
Look at patient face for any wasting of the

temporalis muscle
Wasting of the temporalis will show as
hollowing above the zygomatic arch.
Tone of the muscle:
Ask the patient to clench his teeth and
Now with the fingers of the hand palpate the
masseter and temporalis.to assess their tone
Movement
Ask the patient to open their mouth wide-
o The jaw will deviate towards the side of the
lesion.
Ask the patient to open the jaw against resistance
as follow
o At first Patient mouth should be closed
o Give your hand just below the jaw and
o Give upward pressure with your hand
o Now ask the patient to open his mouth
Examine side to side movement of jaw
o First placed your hand over right side of
lower jaw Give sustain pressure and
o Ask the patient to push your hand with
right lower jaw.
o No it do on left side
89
Reflex
Corneal reflex
Ask the patient to look upwards to the ceiling

and gently depress the lower eyelid.
Very lightly touch the lateral edge of the cornea
with a wisp of damp cotton wool
Look for both direct and consensual blinking
Interpretation
o No response = ipsilateral V1 palsy.
o Lack of blink on one side only = VII
palsy.
Q what is afferent , and efferent and center of corneal reflex ?
Afferent Centre Efferent

Ophthalmic division of Pons Facial nerve or VII
trigeminal nerve or V
Now jerk
Jaw jerk
Ask the patient to let his mouth hang loosely open.
(semi-open)
Place your forefinger horizontally in the midline between
lower lip and chin.
Percuss your finger with the tendon hammer
Feel and watch jaw movement.
o There should be a slight closure of the jaw
o But a brisk and definite closure may indicate an
UMN lesion above the level of the pons (e.g.
pseudobulbar palsy
90
Sensory examination
Like that of sensory examination of limb :
We only see here

light touch &
Pain sensation
First
With wisp of cotton first touch over dorsum
of patient hand and ask the pt can u feel it
Now see it over the face along the three
branch of V nerve
Choose 3 spots to test on each side to make
the examination easy these are
o Forehead,
o Cheek, and
o Mid-way along jaw
Now ask pt to close his eyes and With wisp of
cotton first touch those three area and ask can
he identify the sensation .
For each branch, compare left to right
Now see the pain sensation

o Do same thing with the pointed end of
pain
91
FACIAL NERVE
Facial is a mixed nerve

Motor Muscle of facial expression & nerve to strapideus
Sensory Sensory to ant 1/3 of tongue
Secretomotor
Examination for facial nerve
Inspection
Please look for
1. Any obvious facial deformity

2. Absence of spontaneous blinking of any eye
3. Absence of eye closure / persistence opened eye
4. Loss of naso-labial fold
5. Deviation of angle of mouth
6. Drooling of saliva
7. look at external auditory meatus for blister or vesicle
8. look palate to see the rash / vesicle
7 & 8 is found in Ramsay hunt syndrome
Motor test
Wrinkling
Ask the patient to wrinkle his forehead or
Ask the patient to raise their eyebrows or
Look at the ceiling keeping the head fixed.
It is action of the frontalis muscle of
Eye closure (orbicularis occuli )
Close your eyes tightly and stop me from opening them
92
Blowing cheek
Ask the patient to blow out their cheeks.
Now press over the both cheek with both hand
Watch for air escaping on one side.
Air will be escape through weaker side
Muscle responsible : is buccinators
Show teeth
Now ask the patient to show his teeth
When patient will do it then look at angle of the
mouth for any deviation
In case of facial nerve palsy angle of mouth is
deviated toward healthy side.
Muscle responsible for this is
o Levator anguli oris and
o Resorius
WHISTLE
Ask the patient to purse their lips.

Now ask the patient for whistle for me
o Whistle for me
And look for asymmetry
Muscle responsible for

o Orbicularis oris
Test for hyperacusis For test sensation
Rub the hair on both ear and Tast for sensation

Ask the patient at which ear he hard louder
In this case patient may hard louder in lesioned Anterior 2/3 is supplied by the corda typancia
ear Post . 1/3 is responsible so by glossopharyngeal
Or hold your clock near the patient ear Test: sweet, salty, bitter (quinine), and sour
(vinegar
See the corneal reflex
93
How will be differ between UMN and LMN of facial palsy
1. wrinkling present on affected side 1. wrinkling absent in affected side

2. eye ball can be closed 2.eye ball remained opened on affect sides
3. only lower part of the face involved 3. both upper and lower part involved
4. No hyperacusis or taste is affected 4. Hyperacusis or taste may affected
5. usually associated with hemiplegia 5. not
Cause unilateral facial nerve palsy? Cause of bilateral facial nerve palsy?
Bell's palsy (idiopathic). Guillain-Barre syndrome .
Herpes zoster. Sarcoidosis
Cerebellopontine angle tumours. Lyme
Parotid tumours.
Skull fracture.
Bell s palsy
Bell's palsy is an acute condition caused by swelling of the facial nerve in the facial canal resulting in
lower motor neurone paralysis of VII.
Cause is herpes simplex viral infection in
Treatment of Bell s palsy
1. Oral corticosteroid ---Tab Prednisolone
2. Acyclovior
4. Use eye glass (eye shield) all the time
5. Use eye pad (made of cotton or gauze) during sleep
6. Physiotherapy of upper eyelid muscle
7. Physiotherapy of muscle of angle mouth
Bells phenomenon ?
When u close your eye. Your eye ball will roll upward . This is normal phenomenon . This phenomenon
seen in bells palsy is called bells phenomenon .
Bell palsy remain in short case : After doing examination of VII never forget to see the ear and soft
palate to see vesicle due to ram say hunt syndrome
94
THE GLOSSOPHARYNGEAL (IX) AND VAGUS (X) NERVES
The 9th and 10th nerves control pharynx, larynx and swallow.
GLOSSOPHARYNGEAL (IX) VAGUS (X)

Sensory: pharynx, middle ear. Sensory: tympanic membrane, external auditory
Special sensation: taste on posterior 1/3 of Canal and external ear.
tongue. 1. Proprioception from thorax and abdomen.
Motor: stylopharyngeous. 2. Motor: palate, pharynx, and larynx.
Autonomic: parotid gland 3. Autonomic: carotid baroreceptors
Now start examination of IX & X nerve

1. Talk with the patient to access (ask name ) Bilateral superior laryngeal nerve
To see nasal voice and hoarseness
Dysarthria or
2. Ask the patient for nasal regurgitation present
or not
3. Ask the patient to cough? Damage to the recurrent laryngeal branch of X
To see bovine cough causes dysphonia and a 'bovine' cough
Ask the patient to open their mouth and inspect

the uvula
Is it central or deviated to one side?
If so, which side?
In normal case uvula remain in central and

symmetrical arching of soft platelet
If uvula is central or deviated to any side do the

following :
Ask the patient to say Ah.

Watch the uvula. And soft palate with a torch?
Normally :
Uvula: It should move upwards centrally. with
symmetrical elevation or arching of the soft
palate
Incase of X palsy
Uvula is Deviate to healthy side and soft palate
is pulled to normal side or remain flat on
affected side
eg.in Right X palsy
Uvula is to deviated to left side &
soft palate is pulled to the left or flat on right
95
Nasal regurgitation
Ask the patient to puff out his cheeks with the
lips tightly closed.
Now press over the both cheek with both hand
Look and feel for air escaping from the nose.
Incase of X nerve palsy air will comes out through

nose
Gag reflex
Afferent ---is by IX
Efferent is by X
How will u see gag reflex : we dont do it here
This is unpleasant for the patient and should only
be tested if a IX or X nerve lesion is suspected
(afferent signal = IX, efferent = X).
Ask the patient's to open his mouth wide,

gently touch the posterior pharyngeal wall on
one side with a tongue depressor or other sterile
stick.
Watch the uvula (it should lift up).
Repeat on the opposite side.
96
THE ACCESSORY (XI) NERVE
It is purely motor nerve and has two part

Cranial part Arise from medulla It innervate the
Spinal parts. Spinal cord , anterior horn cells sternocleidomastoids and
of C1-5, trapezii
Examination of the XI
First sternocleidomastoid
Inspection
Inspect the sternocleidomastoids. Look for
Wasting,
Fasciculations,
Hypertrophy, and
Any abnormal head position
Palpate
Palpate the muscle to assess their bulk.
Now movement of sternocleidomastoids?

To test power in the left sternocleidomastoid,
Place your hand on the right side of the patient's chin
Ask the patient to turn the head to the right while you
provide resistance with your hand.
Reverse the procedure to check the right

Sternocleidomastoid
Now see the movement of trapizeus

Inspection :
Stand behind the patient to inspect the trapezius
muscle for wasting or asymmetry
Movement
Ask the patient to shrug the shoulders
Simultaneously you apply downward pressure with
your hands
97
Cranial nerve XII: hypoglossal
It is purely motor nerve

It nucleus lie beneath floor of IV ventricle
Inspection
Ask the patient to open his mouth. Look at the
tongue at rest for
Wasting, (increased fold )
Fasciculation or (small wriggling movement)
Involuntary movement.
Tongue
Now Ask the patient to protrude the tongue.
Look for deviation of tongue present or not
Usually deviated toward the side of lesion
Power or movement of the tongue
Place your hand on out side of the right cheek
and ask the patient to press it with tongue from
inside
Now repeat it in the left side
SPEECH
Assess speech by asking the patient to say
'yellow lorry'.
Assess hypokinesis of tongue movement by
asking pt say (lah, lah, lah ) as quickly as
possible .
98
BULBAR PALSY AND PSEUDOBALBAR PALSY
Type BULBAR PALSY PSEUDOBALBAR PALSY

Lesion It is LMN lesion It is UMN lesion
Site of lesion Medulla Bilateral internal capsule ., due to
recurrent stroke
Tongue Wasted , fasciculation & flaccid Small and stiff or spastic
Jaw jerk Absent Brisk
Speech Nasal Slow , slurred , indistinct / hot potato
speech
Nasal Present Absent
regurgitation
Emotion Normal Labile / dementia
Cause of bulbar palsy Cause of pseudobalbar palsy

MND Bilateral recurrent Stroke
GBS Multiple sclerosis
Brain stem infarction
Syrignobulbia
Neurosyphilis
Which nerve involved in bulbar palsy?
The nerve involve are IX, X ,XI , XII
What are symptoms of bulbar palsy?
3 D
DDysphagia
DDysarthria
DDysphonia
Why called bulbar palsy?
As the nerve involved in bulbar palsy are situated in medulla. Anatomically medulla have two
forward bulging that previous medulla was called bulb.
Why called pseudo bulbar palsy?
As the symptoms are like that of bulbar palsy. But lesion not in the medulla it is in the
cerebral cortex. That why it is call pseduobulbar palsy that false bulbar .
99
Short case Examine the 3 rd nerve ?
rd
What r the feature of 3 nerve palsy?
look at the patient face (ptosis ) what
Ptosis (complete ) examination you want to do ?
Divergent squint
Pupil dilated
Both direct and indirect light reflex are
lost
Loss accommodation reflexes
unable to move the eye upward
,downward and medially
what will be the direction of eye of in III nerve

lesion ?
eye ball will rotated down ward and laterally
Cause of unilateral ptosis Bilateral ptosis

1. 3rd nerve palsy 1. Myasthenia gravis
2. Horners syndrome 2. Tabes Dorsalis
3. trauma 3. myopathy
4. congenital a. Myotonia dystrophica
b. fascio-scapulo humeral
myopathy
c. occulo pharyngeal myopathy
4.bilateral horners syndrome
VI nerve plasy
100
101
Cerebellar sign
Cerebellar lesions cause incoordination on the ipsilateral side
What examination u will do if u r asked to do cerebellar sign?

Nystagmus
Scanning dysarthia
Tremor
Finger nose test
Rebound phenomenon
Rapid alternating movement
Heel shin test
Jerk
Gait
1st see Nystagmus of the patient
Ask the patient to sit and look straight in front

and u look at patient eye see any nystagmus
present or not
Now see any nystagmus by movement of the
eye ball (horizontal or vertical )
Keep your finger straight in front of the eye
(bellow ) and 2 to 3 feet from the patient
Move the finger laterally , patient should follow
up to 30 0 left and right and keep your finger
for 5 sec
Donot move > 450 from central beyond which
nystagmus is physiological ..
Now look that the nystagmus is
o Central horizontal or vertical
o Jerky or pendular
o Fast component or slow component
Scanning dysarthia
Ask the patient to say a word of poly syllable like British constitution or artillery or i
In bangla
The patient will utter this ward syllable by syllable and patient speech will be jerky slurred and
explosive.
Look for titubation :

Head nodding it is the to-fro movement of hand
Two types ----yesyes ; upward and downward movement of head or
NoNo ; side to side movement of head
Look for any tilting of shoulder
Tilting of shoulder toward site of lesion
102
Tremor
Tremor
Look for intention tremor
Ask the patient to hold your pen or
Ask the patient to hold the cup / glass
If patient have intention tremor --------
You will find that his hand will be trembling at
end of the task such as
Pt will feel difficulty or trembling
during holding the pen
Finger nose test
Finger-nose test
Ask the patient to touch his nose with the tip
with his index finger.
Now hold your own finger in front of the
patient arm reach and ask the patient to touch
tip of that fingers with his index finger
Ask the patient to repeat the movement
between nose and target finger as quickly as
possible
To make the test more sensitive change the
position of your target finger (move your
finger left or right , bellow or above )
Care fully look for
Look for intention tremor (worse as it
approaches the target)
and past-pointing (missing the target
entirely).
103
Rebound phenomenon
Ask the patient to hold both arm out and
front and maintain this position.
Push the patient's both arm quickly
downward and release sudeinly observe the
returning movement
In case of cerebellar lesion ipsilateral arm
will fly past the starting point.
This occur due to the failure of the reflex
arrest
Rebound phenomenon
Ask the patient to flex his both elbow
pull on the patient's flexed forearms toward you
and ask to pull it toward himself (as if testing
elbow flexion power)
Suddenly relase the pressure and let the
forearm go .
If the patient has cerebellar lsion due to lack of
co-ordination, the patient will hit his/herself in
the face on ipsilateral side
104
RAPID ALTERNATING MOVEMENT
At first keep the left the elbow 90 0 flex with

keeping the palmer surface of left hand up
ward and fore arm is in supinated
Ask the patient to repeatedly supinate and
pronate his right forearm in such way that
palm and dorsum of his right hand clap the left
hand palm to palm and dorsum to palm and so
on
Now do this with left fore hand and hand
Interpretation
Slow and clumsy or inability to do it is called

dysdiadokokinesis.
Heel shin test

Ask the patient to lie supine on the
examination couch
Ask the patient to raise right leg and place
the heel on the left knee and
Then slide the heel tip up and down over the
shin between left knee and ankle.
Now do it in opposite side
Jerk
Ask the patient to sit down on the examination

couch with hanging both leg .
Now tap with tendon hammer over patellar
tendon
Normally the leg will swing back ward and
forward
If this swing movement is occur more than 5
time then is will called pendular jerk .
105
Gait
o Ask the patient to stand up

o Look care fully if patient will stand in broad
base that means both feet will remain widely
apart
o Then tell him to close together his feet
o if patient have cerebella lesion patient
will fall immediately
Reeling and drunken gait :
o if u ask the patient to walk

o the patient will walk like drunken with
tendency to fall toward the side of lesion
Tandem gait
If the patient is asked to walk with 1 foot

immediately in front of the other (ie, heel to toe). A
tendency to sway or fall to one side indicates
ataxia, suggesting ipsilateral cerebellar dysfunction
What are the classical triads of cerebellar lesion?
o The classical clinical triad of cerebellar disease is

Ataxia,
Atonia,
Asthenia
What are the causes of cerebella lesion?
o Stroke
o Cerebellar abscess
o ICSOL
o Multiple sclerosis
o Drugs (phenytoin , carbamazepine ) and alcohol
o Paraneoplastic lesion
106
Cause of cerebellar lesion in child (do not read ) Name some degenerative lesion (no to read )
o Friedrich ataxia o Progressive cerebellar degeneration

o Multiple sclerosis o Olivo-ponto-cerebellar degeneration
o Wilsons disease o Shy Dragger syndrome
o Drugs
How are cerebellar signs localized?

o Gait ataxia (inability to do tandem walking): anterior lobe (palaeocerebellum).
o Truncal ataxia (drunken gait, titubation): fiocculonodular or posterior lobe (archicerebellum).
o Limb ataxia, especially upper limbs and hypotonia: lateral lobes (neocerebellum).
What is site of cerebella lesion?

o Usually ipsilateral
What r cerebellar sign?

Titubation
Tilting towards the site of lesion
Nystagmus
Scanning dysarthia
Intention Tremor
Past pointing /dysmetria (Finger nose test)
Rebound phenomenon
Dysdiadochokinesis (inability to perform Rapid alternating movement )
Incoordination (Heel shin test )
Pendular Jerk
Gaitataxia ,
Hypotonia
107
neck rigidity
kernigs sign
108
Eye opening
Spontaneous 4
To speech 3
To pain 2
No response 1
109
Motor response
Obeys 6
commands
Localizes to 5 brings hand up beyond chin to

pain: supraorbital pain
withdrawal to 4 No localization to supraorbital

pain: pain but the patient flex the
elbow .if you give nail bed
pressure
Abnormal 3
flexion to pain
Extension to 2 extends elbow to nail bed
pain: pressure
No response 1
110
Verbal response To remember OC in AC now
5
O--Orientated
Know place , person , time
4
C---Confused
talks in sentences but disorientated
3
in A-- Inappropriate talk Utter occasional words rather than sentences
2
in C-- Incomprehensive Groans , grunts , but no ward
1
now ---No vocalization / none
111
Examination of motor system
Upper limb and
Lower limb
In Examination of motor system of lower limb u have t o look the following

Wasting
Fasciculation
Bulk of the muscle
Tone of the muscle
Power of the muscle
Jerks or reflex
o Superficial
Abdominal reflex
Creamister reflex
o Deep
Keep jerk
Ankle jerk
Clonus
o Patellar Clonus
o Ankle Clonus
Coordination
o Heel shin test
Now start examination of lower limb

Stand right side of the patient and give salaam and introduced your self that I am medical student
of 5th year .
Take consent from the patient that I am going to examination you lower limb for my purpose and
It will not hurt u. can I proceed?
Now expose the patient lower limb up to such a level that lowers 2/3 of both thighs easily visible.
First look the patient lower limb and during inspection please forward and draw the attention
examiner that u r looking at lateral surface of left leg and thigh
Wasting and fasciculation
1. Wasting
Any wasting present or not
If present then
Unilateral or
Bilateral
Wasting is in the thigh or
leg or both
2. Fasciculation
First only inspect any fasciculation present or not
If not present then gently tap with four fingers over every quadrant of muscle and look any
fasciculation visible or not
Tap over
Medial and lateral surface of right and left thigh
Medial and lateral surface of right and left leg / cuff muscle
Motor system examination 112

2. Bulk of the muscle
Seen by two method
By using both hand
With measuring tap
Using hand
By using both hand together try to
circumscribed right and left thigh one after
another and see any gross asymmetry present or
not in any side .
With Measuring Tap

Measure the circumference of thigh
At first on right thigh

o Measure the circumference of thigh at
point 15 cm above the upper border
patella or other boney prominence with
measuring tap.
o suppose it is 35 cm
Now on left thigh
o Measure the circumference of this
thigh at same distance (that is 15 cm
above the upper border of patella) with
measuring tap.
o Normally it must be 35 cm
o If it less than that u should think that
there is muscle wasting in left thigh
Now measure in such way circumference of leg
muscle / cuff muscle
3. TONE OF THE MUSCLE

Tone of the muscle sees in three way :
Step 1.
Palpation of muscle of thigh and leg with both palm and fingers of hand & roll the leg side to side
or tro fro
Step 2 :
Lift the right leg by griping it at foot with right hand and
Suddenly allow it to fall.
Keep the left hand below the right such a position when the leg will it will fall on you left hand .
INTERPRETATION
If patient muscle tone less or hypotonia
Then the leg will immediately on your hand
If patient tone is normal
Then the limb will fall gradually

Step: 3
Lastly passive movement of limb
A .Do flexion & extension of knee joint.
Keep the knee and hip semi flex
Keep left hand lower part of the right
popliteal fossa and
Then keep right hand on the planter
surface of right foot
Do flexion and extension of knee joint
with right hand
Now do it on left lower limb
B. Passive movement of ankle joint
Now keep the knee straight
Keep Left hand in right cuff muscle
Grip the planter surface of right foot
with right hand
Do flexion , extension &
circumference move of ankle
Now do this in left leg:
3. POWER OF THE MUSCLE

Step one:
First ask the patient to lift his right leg keeping the knee
extend or with out bending the knee
If he able to this do this then his muscle power is > 3
Now u have to see the patient movement against resistance
For HIP JOINT Remember 42 4

First see 4 movement of hip flexionextension adduction abduction
hip flexion Hip extension
keep both hand on knee joint give sustained Keep hand below the lower part of both
pressure and ask the patient to lift up his leg thigh simultaneously and ask the patient to
with out bending the knee press over hand keeping the knee straight

Adduction: Abduction
Now keep both hand outer side of both thigh Now keep both hand inner side of both thigh
keep sustain pressure and ask the patient to keep sustain pressure and ask the patient to
apart both thigh with out bending the knee give pressure on your hand with both thigh
together
FOR KNEE JOINT (PULL AND PUSH)

Keep the leg semi flex position
Grip the cuff muscle or leg with both hand
o )
To see flexion : To see extension
Now ask the patient to forcefully extend this Keep sustain pressure pull the leg toward your
knee and when you will give opposite pressure self and ask the patient and forcefully flex knee
(Here patient will push to extend knee and you will (in easy language u will pull the leg toward ur
push to prevent it ) side and pt will pull toward his side )
FOR ANKLE JOINT (4-movement, planter flex. Dorsi flex., inversion and eversion )
Planter flexion Dorsi flexion
Keep two hands just behind the patients Keep two hands in front of the patients
foot or over palmer surface of foot foot or over dorsal surface of foot
Keep sustain pressure and ask the patient to Keep sustain pressure and ask the patient to
push back ward push forward

INVERSION EVERSION
Keep two hands lateral side of the patients Keep two hands ,medial side of the patients
foot foot
Keep sustain pressure and ask the patient to push Keep sustain pressure and ask the patient to
out ward /laterally or apart the feet push in ward
If the patient unable to lift up leg

spontaneously then muscle power < 3
Test do to see muscle power is two or less :
o Ask the patient to move leg side to
side
o With the hand one leg take away
from other and ask the patient to
keep the leg in previous
Position
If patient is not able to do side to side

movement then muscle power is less then 1
To see muscle power one or 0 ask the
patient to move his great toe
if he can move his great toe .: muscle
power is 1
If he can not then muscle power is : 0
4. Jerks or reflex
o Superficial
Abdominal reflex
Creamister reflex
o Deep
Keep jerk
Ankle jerk
Deep reflexes
KNEE JERK
Step1. patient will be in lying position. Tell the patient what will u going to do the patient
Step 2. Expose the patient limb up to mid thigh
Step 3. Semi flex the right knee join in such position that ankle must touch the bed
Step 4. keep your left hand just over back of the knee joint
Step 5. Now identify the patellar tendon and hold the hammer in its far end with right hand
Step 6. Now strike over the patient patellar tendon in such a way that there will be only the swinging
movement of right wrist joint not the elbow (elbow remain fix) .
Step 6. during striking your should look at patient quadriceps muscle for any contraction
Some body prefer to talk with the patient by asking some question(name , address ) during
Striking over the patellar tendon to divert the patient attention and keep the muscle relax
What will u do if u not able to elicited jerk ?

I will do Jandrassic maneuver . this describe
bellow :
Step . ask the patient to interlocked his hand
fingers with each
Step . instruct the patient when I will tell 1,2,3
at beginning of uttering 3 you will pull your
interlocking hand fingers with other
Step 3. you also strike at the beginning of
uttering 3
Step 4. at same time u will look at patient s
quadriceps muscle for any muscle contract or
movement of leg
Step 5. if no contraction is present then pts jerk
is absent

ANKLE JERK
It is more difficult to elicit

Step1. Patient will be in lying position. Tell the patient what will u going to do the patient
Step 2. Expose the patient limb up to mid thigh
Step 3. Hold patients planter surface of right foot with left hand & flex the knee it in such a
position that right leg will remain on left leg keeping the right ankle joint outer side the left leg
Step 4. Gently push the right foot with left hand to straighten the tendoachilis .
Step 5. Be cautious do not push hardly or strongly that it tighten the achilis or contract the
muscle
Step. 6 . Hold the hammer in its far end with right hand Now strike over the patient achilis
tendon in such a way that there will be only the swinging movement of right wrist joint not the
elbow (elbow remain fixed ).
Step 6. during striking your should look at patient cuff muscle for any contraction.
Some body prefer to talk with the patient by asking some question (name, address)
during striking over the patellar tendon to divert the patient attention and keep the
muscle relax..
If u can not elicit the reflex do the jandrassik maneuver
Some body prefer not to keep the right leg over left rather than they like to keep
the both leg in rhomboid position by semi flexing the both knee over bed
o Superficial
Abdominal reflex
Creamister reflex

ABDOMINAL REFLEX: (T-812)
Step one. The patient should be lying on their back, relaxed,

Step two. Abdomen will be exposed.
Step three. Using an orange stick or back of the hammer , stroke briskly but lightly in a medial
direction
First in the right upper quadrant (started just above the level of umbilicus from
downward to upward and lateral to medially toward midline )
Next left upper quadrant (same as )
Then right lower quadrant (started just bellow the level of umbilicus from up ward
to downward and lateral to medially toward midline)
Then left lower quadrant (same )
This make a imaginary diamond shape or rhomboid shape
Interpretation
o The normal response is contraction of the underlying muscle with the umbilicus moving
laterally and up or down depending upon the quadrant tested.
Cremasteric reflex (L1-2)

Usually not done
With the male patient standing and naked from the waist
down
Now Abduct and externally rotate the patient's thigh
Use an orange stick to stroke the upper medial aspect of
the thigh
Normally the ipsilateral cremaster muscle will contracts
and
The testicle on the side stimulated will move upward with
in scrotum
Cremasteric reflex (L1-2)

Usually not done
With the male patient standing and naked from the waist down
Now Abduct and externally rotate the patient's thigh
Use an orange stick to stroke the upper medial aspect of the thigh
Normally the ipsilateral cremaster muscle will contracts and
The testicle on the side stimulated will move upward with in scrotum

PLANTER REFLEX
Step1. Patient will be in lying position
with outstretch leg
Step 2. Tell the patient what will u going
to do the patient and it will not hurt you.
Step 3. Stroke the patient's sole with a
blunt object (key or orange stick) along
the lateral border of the sole of the foot
towards the little toe.
Step 4. . If there is no response, the stroke
can be continued along the ball of the
foot to the base of the big toe.
Step 5. as soon as you will get response of
great toe u will stop striking
immediately at that point
Watch the big toe for its initial movement
o Plantar flexion.
o Dorsiflexion.
o An absent response./
equivocal
o withdrawal
Normal response is plantar flexion

of the big toe (that will goes down
ward ) and adduction of the other
toes. .
Upper motor nerve lesions will
cause the big toe to dorsi flexion
.(that will go upward ) abduction
(fanning out ) others toes
If the leg is withdrawn and the heel
moves in a ticklish reaction, this is
called a withdrawal response and
the test should be repeated.
If there is no movement of great toes then
it is called absent or equivocal reaction

CLONUS
o Patellar clonus
o Ankle clonus
Ankle clonus;
Step one : patient will be in lying position

Step two : Flex the right knee at 90 0
position .do it by resting the left hand in
the back of the knee and Right hand will
support the planter surface / back of the
right foot and thumb will be in Front of
foot. Patient heel will not touch the
ground
Step three: Now suddenly push the back
of foot (dorsiflexion ) with the right hand
and care fully remove thumb Of the
right hand otherwise it will obstruct the
clonus .
Step four : look for rhythmic series of
contractions evoked by sudden stretch of
the muscles --it is the clonus (if > 3
movement present then it is clonus )
PATELLAR CLONUS / knee clonus

Step one : patient will be in lying position
and relax with knee extended,
Step two : expose the patient limb up to
mid thigh
Step three : now sharply push with your
thumb and forefinger above the patella
towards the foot & Keep sustained
pressure for a few second
Step four : if clonus present then u will
observe that patella is moving forward and
back rhythmically
Coordination test:
/Heel-shin test
Step:one : patient will be in lying position
Step two : Ask the patient to raise right leg
and place the right heel on the left knee
Step three : then slide the right heel tip up
and down over the shin between right knee
and ankle

Snout reflex Lightly tap the lips. An abnormal
response is protrusion of the mouth
Grasp reflex Firmly stroke the palm from the

radial side. In an abnormal
response, your finger is gripped by
the patient's hand
Palmomental Apply firm pressure to the palm

reflex next to the thenar eminence with a
tongue depressor. An abnormal
response is puckering of the chin.
Glabellar tap Stand behind the patient and tap

repeatedly between the eyebrows
with the tip of your index finger.
Normally the blink response stops
after 3 to 4 times.

Question and answer regarding motor examination of lower limb:
What is upper motor neurone?

Pyramidal cell and their axon up to anterior horn cell. And up to their homologous neurone in brain stem
What is lower motor neurone?

Anterior horn cell and their homologous neurone in brain stem and their axon up to effector organ
Write difference between UMN and LML lesion?
Upper motor neuron lesion Lower motor neuron

Fasciculation Absent Present
wasting Absent Present
Tone Hypertonic Hypotonic
Reflex Deep reflex exaggerate Both superficial and deep reflex
are lost
Planter Extensor Flexor
Clonus Present Absent
Paralysis Spastic paralysis Flaccid paralysis
Q. name some example of UMNL Q. name some example of LMNL

Stroke GBS
ICSOL Poliomyelitis
Cerebral abscess MND
Multiple sclerosis Diabetic amytrophty
Spinal cord compression Charcot marie tooth disease
Acute intermittent porphyria
Paraneoplastic syndrome
Cause of hypertonia Cause of hypotonia
UMNL(spasticclasp knife ) LMNL

Extrapyramidal lesion (cogwheel / lead pipe) Hypokalaemia
Tetanus Cerebellar resion
Catatonic state Dorsal column lesion
Poly neuropathy
Write down difference between spasticity and rigidity

Spasticity Rigidity
It is a sign of UMNL It is a sign extrapyramidal lesion
Spasticity is a velocity-dependent resistance to Rigidity is a sustained resistance throughout the
passive movement range of movement
Here only agonist muscle give resistant to Here both agonist and antagonist give resistance
movement
In UMNL it calledclasp knife In extrapyramidal lesion two type
Cog wheel and lead pipt
What does u mean by muscle tone?
It is the state of partial contraction of muscle.
Please tell the MRC grading of muscle power ?

Medical Research Council scale for muscle power
0 No muscle contraction visible
1 Flicker of contraction but no movement
2 Joint movement when effect of gravity eliminated
3 Movement against gravity but not against examiner's resistance
4 Movement against resistance but weaker than normal
5 Normal power
4- When 25 %resistance is given
4 When 50%resistance is given
4+ When 75 %resistance is given
What do u mean by paresis and plegia , hemi, mono , para , tetra plegia ?
Paresis Partial paralysis Jerks grading

Plegia Complete paralysis
Monoplegia Involvement of a single limb 0 = absent
= present only with reinforcement
Hemiplegia Involvement of one-half of the body
1+ = /less than normal
Paraplegia Paralysis of the legs 2+ = normal
Tetraplegia Paralysis of all four limbs 3+ = brisk/more than normal
What is the reflex arc?

Reflex is consisting of an afferent (sensory) and an efferent (motor) neurone with one synapse between
(i.e. a monosynaptic reflex).
Where is the center of the jerk?

In the spinal cord
Name the root value of jerk / reflex?
Planter S1
Ankle jerk S1 S2
Knee jerk L3 L 4
Supinator jerk C5 C6
Bicep jerk C5 C6
Tricep jerk C6 C7
To remember from below to upward: 11, 2 -----3, 4 ------5, 6 ---5, 6---67

Root value of abdominal reflex T8---12

What are the causes of exaggerated jerk or reflex? What are the causes absent jerk or reflex?
UMNL LMNL
Hyperthyroidism Peripheral neuropathy
Cerrebellar lesion (pendular ) Dorsal column lesion
Hypo kalaemia
Name the muscle, tendon and root value of jerks ?
Jerks Root value Tendon Muscle

Ankle S1 S2 Tendo-achilis Cuff muscle
Gastroconemius and
soleus
Knee L3 L 4 Patellar tendon Quadriceip muscle
Vastus medialis
Vastus lateralis
Vastus intermediate
Abdominal reflex T812 X Abdominal muscle
What is cause of delayed relaxation of ankle jerks?

Hypothyroidism
How will u see delayed relaxation of ankle jerk?
Step 1. Ask the patient to knee down position on the bed in such way that patient ankle and tendon
remained out side bed
Step 2. Now tap over the tendon
Step no 3 Now look for contraction of the Gastroconemius and soleus muscle
What is hard sigh in upper motor lesion?

Planter reflex or babyniski sign
Where it is Found ?
UMNL
Child bellow one years
In deep coma (Bilateral )
Post epileptic period
Why child bellow one year shows babyniski sign positive ?
It occure due to lack of myelination of pyramidal tract. myelination occur with 6 to 12 months of after
birth .

Sensory examination
Analgesia - The absence of sensibility to pain
Hypoalgesia - reduced pain sensibility
Hyperalgesia - an increased pain sensibility to mildly painful stimuli
Allodynia - pain perception from a normally non-painful stimulus
Hyperpathia - pain perception that spreads out from the point of the stimulus or outlasts the
stimulus in time
Paraesthesiae - tingling sensations sometimes so intense as to be painful, occurring spontaneously
or in response to light cutaneous stimuli
To remember it
just pocket L1
full pocket L2
at the end of full pocket up to end of knee joint L3
now divide the rest of leg in two part medial and lateral half
medial half supplied by ----L4
lateral half + dorsum of foot (except 5 th toe )L5
sole of foot ---S1
when u lie / sit down the part of limb touch bed or chair S2
around the perineum S 2,3,4
Sensory Examination 126

Sensory examination
Sensory path way is ascending pathway:

It arise from receptor ----spinal nerve dorsal root ganglia enter spinal cord
In spinal cord there is two path way for carrying the sensory modalities
The posterior (dorsal) columns. Convey the proprioception (joint position sense) and vibration
and in spinal cord it remains ipsilateral (same side )from the point of entry in up to the medulla
and cross over go to medial leminiscus
Lateral Spinothalamic Tract Convey the Pain and temperature sensation and in spinal cord it
cross within one or two segments of entry to the contralateral spinothalamic tract.
All sensory fibres relay in the thalamus before sending information to the sensory cortex in the
parietal lobe

Sensory examination
Name different sensation with their pathways in spinal cord
Modality Pathway
Light touch
Proprioception Large fast-conducting axons
Dorsal columns
Vibration
Medial lemniscus
Two-point discrimination
Pinprick (superficial pain)
Smaller slower-conducting axons
Deep pain
Spinothalamic tracts
Temperature
Stereognosis
Parietal cortex (only valid if peripheral
Graphaesthesia
sensory function intact)
Now examination of sensory system of a patient:

We see the following in
Light touch
Pain
o superficial pain
o Deep pain
Temperature
Vibration
Joint position sense
Other
o Stereognosis
o Graphaesthesia
How will examine the light tough / fine touch

Take a wisp of cotton wool (take cotton and roll it to make a point end )
Step 1. stand right side of the patient
Step 2. take consent as u learn in motor exam
Step 3.expose the both lower limb
Step 4. Instruction the patient that
o Look I m touching your forehead with cotton.
o R u feeling the touch sensation on forehead.
o The patient will see yes.
o Now I will do this in different parts of your lower limb. Your eye will close and u will tell
me which limb you get the touch with this cotton.
o If do not feel or recognized it tell me you cannot identify it
Step 5. Ask the patient to close your eye
Step 6 Start touching with this cotton wisp right and left leg alternately and ask the patient to
Localized it(ask the pt which limb u touch ). Start according to dermatome and ascend from
distal to proximally such as
(first great toe dorsum medial and lateral surface of legknee thigh )
Sensory examination
How to examine the pain sensation

Pain
o superficial pain
o Deep pain
SUPERFICIAL PAIN
It usually sees with the pointed end of pin .
Step 1-3. as before (do not repeat if u it during fine touch examination )
o Look I m touching your forehead with pointed end of pin .
o R u feeling the sensation on fore head .
o The patient will see yes .
o Now I will do this in different parts of your lower limb . Your eye will closed and u will
tell me in which limb u get pain sensation when I touch u with pin .
o If do not feel or recognized it tell me you cannot identify it
Step 5-6 do it same as fine touch sensation
DEEP PAIN
o (Usually we do not do it but u do only when u r ask to do it?)
It is usually seen by
o Squeeze the muscle bellies, e.g. calf, biceps
o apply pressure to finger or toe nail beds
o Do not apply pressure with an instrument, e.g. pen.
Temperature
Usually not seen
When tested, test tubes containing hot and ice-cold water are used
These tubes are touched in each dermatome same as above and
Ask patient Is he feeling cold or hot respectively

Sensory examination
JOINT POSITION SENSE
o Step 1-3. As before (do not repeat if u do it during fine touch

examination )
o Step 4. With the patient's eyes open demonstrate the
procedure
o Hold the distal phalanx of the patient's great toe at the
sides with right thumb and index finger and fix the
distal ITP joint with left thumb and index finger
o Move it up and down
o Ask the patient to respond with 'up' or 'down' as you
make these movements
Step5. Now asks the patient to close the eyes and Identify the
directions in a random sequence of small movements (e.g. up,
down, down, up).
Test both large toes (or middle fingers).
If impaired, move to more proximal joints in each limb.
Vibration
It is seen with tuning fork having 128 HZ
Step 1-3. As before (Do not repeat if u do it during fine touch

examination )
Look I m touching this instrument in your sternum / forehead
and tell me what ur feeling
Tap the arm of the fork on ur palm and place bottom of the fork
on patient sternum or fore head .and ask the patient
R u feeling the vibrating sensation on your sternum / fore head .
The patient will see yes .
Now I will do this in different parts of your lower limb . Your
eye will closed and u will tell me in which limb u get this
vibration sensation when I will place it on u .
If do not feel or recognized it tell me you cannot identify it
Step 5.
Now place it on the tip of the large toe
o If patient can identify it then u need not go up ward
o If sensation is impaired, place it on the interphalangeal joint
and progress proximally such way until u get the respond
The medial malleolus,
Tibial tuberosity and
Sensory examination
Anterior iliac spine
Step 1. Use a two-point discriminator (an instrument like a pair of
blunt-tipped school compasses) or an opened-out paper clip.
Ask the patient to close the eyes.
Apply either one or two points to the pulp of the patient's
forefinger
ask whether one or two stimuli were felt.
Then adjust the distance between the two points to determine the
minimum separation at which they are felt separately.
Test both fingers and thumbs
The minimum distance of two point discrimination is 5 mm
STEREOGNOSIS :
Ask the patient to close the eyes.

Place familiar small objects (e.g. coin, key, matchstick) in the patient's hand
Now ask the patient to identify what they are after feeling them (stereognosis).
If patient failed to recognized then it called Astereognosis
GRAPHAESTHESI
Ask the patient to close the eyes

Using the blunt end of a pencil or orange stick trace letters or digits on the patient's palm.
Now Ask the patient to identify the figure graphaesthesia
Failure to identify this is called agraphaesthesia
Romberg's sign
A further test of joint position sense. When proprioception is lost in the
limbs, patients can often stand and move normally as long as they can
see the limb in question.
o Step 1 Ask the patient to stand up
o Step-2- then tell him to close together his feet
(if patient have cerebella lesion patient will fall
immediately )
o Step3 Now ask the patient to close his eyes
o Step4 If there is loss of proprioception, the patient will lose their
balance and fall
o If this happened then Romberg test is positive
o Step5 asking them to open their eyes again immediately if they
haven't already done.
o So During examination take care that you are able to safely catch
the patient in the event of a fall
o Incase of upper limb u have to do every thigh similar and

Sensory examination
o U has to known dermatome of upper limb
o Also have to know the ulnar/radial / medial nerve distribution in hand
Nerve supply as dermatome
Ulnar nerve (C8-T1)

Motor
o all muscle of hand expect LOAF
Sensory:
o ulnar side of hand, little finger and half
of ring finger
LESION :
Claw hand
Wasting hypothenar muscle
Froment s sign :
o Ask the patient to grasp a piece of
paper between their thumb and
forefinger .
o Alternatively, ask them to make a fist.
The thumb is unable to adduct so will
flex instead
Median nerve (C6-T1) Radial nerve (C5-C8)

Motor: Motor:
LOAF (lateral 2 lumbricals, opponens pollicis, o Triceps, brachioradialis, and extensors of the
abductor pollicis brevis and flexor pollicis brevis). hand.
Sensory: Sensory:
thumb, anterior index and middle fingers as well as small area over the anatomical snuff box
some of the radial side of the palm lesion:
Lesion:
Weakness and wasting of the thenar eminence. Look for wrist drop . If not obvious, ask the
o carpel tunnel syndrome! patient to flex at the elbow, pronate the forearm
and extend the wrist (you may need to
demonstrate). Wrist weakness will become
clear.

Sensory examination
Q. where u get claw hand ? Ulnar nerve palsy

Q. where u get wrist drop ? Radial nerve
Q. where u get carpel tunnel syndrome ? Median nerve
Q. sensory supply of ulnar n ulnar side of hand, little and half of ring finger(1 )
Q. sensory supply of medial nerve n 3 finger (thumb, anterior index and middle fingers
and ring finger) &
Q. sensory supply of radial n Anatomical snuff box
Q n supply of thenar and hypothenar Thenar medial n , hypothenar ulnar
Q name nerve supply of muscle of hand All the supplied by Ulnar nerve except thenar and
LOAF (lateral 2 lumbricals, opponens pollicis,
abductor pollicis brevis and flexor pollicis brevis).
Q cause of foot drop ? Lesion in the common peroneal nerve

Examination of spine
Look
Feel
Move
Take consent from patient
expose the patient ,take shirt off and expose up
to mid thigh
With the patient standing, inspect posture from
behind, the side and the front, noting any
deformity like
o Scoliosis: lateral curvature of the spine
o Kyphosis: forward bending of spinre
o Lordosis: backward bending of the
spine.
o Gibbus: localized swelling over the
spine
Feel
Ask the patient any pain present or not
Palpate the spinous process and para spinous
tissue with tip of the fingers and indentify and
swell or deformity
Now warn the patient that u will percusss on his
back .
lightly percuss the spine with your closed fist
and note any tenderness.
Movement
Flexion. Ask the patient to try to touch his

toes with his legs straight.
Extension. Ask the patient to straighten up
and lean back as far as possible (normal 10-
20 from neutral erect posture).
Lateral flexion. Ask the patient to reach
down to each side touching the outside of
the leg as far down as possible while
keeping the legs straight
MKS 134
schober test :
Schober's test for forward flexion.
Mark the skin in the midline at the level of the
dimples of Venus; (mark A).
Using a tape measure, draw two marks,
o one 10 cm above (mark B) and
o one 5 cm below this (mark C).
Place the end of the tape measure on the upper
mark (B) and ask the patient to 'touch the toes'
The distance from mark B to mark C should
increase from 15 to more than 20 cm
Root compression tests

It is SLR straight leg raising test, This tests for L4, L5, S1 nerve root tension, e.g. in L3/4, L4/5 and
L5/S1 disc prolapse (respectively)
The patient should be in lying dorsal position
Now ask the patient to lift up his legs keeping

knee straight .ask the patient to inform u if he
notice any pain and keep the leg in that
position.now measure the angle between the couch
and the leg . normal angle is (80-90 0)
Not need to learn
Bragard's test :
When patient complained pain keep the leg fix in
that position and now do dorsiflexion of foot
(Bragard's test). it will increased pain by
increasing Tension at root level .
Now flex the knee and the pain will disappear as
root tension relieved
o 'bowstringing
o Now give Pressure over centre of popliteal
fossa on posterior tibial nerve
o which is 'bowstringing' across the fossa causing
pain locally and radiation into the back.
MKS 135
Femoral nerve stretch test.
the patient will be lying on the front (prone)
The pain may be triggered by (B) knee flexion
alone or (C) in combination with hip extension
Flex the knee it will increased pain
Now extend the hip keeping the knee flex . . it will

incrased pressure in the root . it increased pain
Take consent of the .1

patient exposed .2
Expose the knee joint
Both legs should be fully
examination of knee joint

Look
1. Take consent of the patient and ask if there any

pain present or not
2. Both both knee joint including lower 2/3 of
thigh should fully be Expose.
3. look for the following
any swelling
redness
scar , sinus and
4. any postural deformity genu valgum (knock-
knee) or genu varum (bow-legs).
5. look for any wasting or flexor deformity
6. If wasting is present, measure the thigh girth in
both legs at a selected distance (say 20 cm)
above a defined fixed bony landmark - the tibial
tuberosity.
7. At last see the popliteal fossa for bakers cyst .
MKS 136
feel
1. See temperature with back of the hand
2. Tenderness
3. Synovitis
4. Synovial thickening
5. The patellar tap.
a. With the knee extended, empty the
suprapatellar pouch by sliding your left
hand down the thigh until you reach the
upper edge of the patella.
b. Keep your hand there and with the
finger tips of your right hand press
down briskly and firmly over the patella
.
c. In a moderate-sized effusion you will
feel a tapping sensation as the patella
strikes the femur. You may feel a fluid
impulse in your left hand.
6. The 'ripple test'
7. feel the popliteal fossa for any swelling
The 'ripple test'
With the knee extended and the quadriceps

muscles relaxed, empty the suprapatellar pouch
as for the patellar tap
Now with extended fingers, stroke the medial
side of the joint. Now stroke the lateral side of
the joint and watch the medial side for a bulge
or ripple as fluid reaccumulates on that side
MKS 137
Move Passive flexion and extension. Normally the
knee can extend so that femur and tibia are in
Active flexion and extension. With the patient longitudinal alignment. Record full extension as
supine: 0. A restriction to full extension occurs with
bucket-handle meniscal tears, osteoarthritis and
Ask the patient to flex the knee up to the rheumatoid arthritis. To assess hyperextension,
chest and then extend the leg back down to lie lift both legs by the feet. Hyperextension (genu
on the couch (normal range 0-140). Feel for recurvatum) is present if the knee extends
crepitus between the patella and femoral beyond the neutral position. Up to 10 is normal
condyles suggesting chondromalacia patellae
(especially in younger female patients) or
osteoarthritis. If there is a fixed flexion
deformity of 15 and flexion is possible to 110
record this as a range of movement of 15-110.
Ask the patient to lift the leg with the knee kept
as straight as possible. If the patient cannot keep the
knee fully extended an extensor lag is present,
indicating quadriceps weakness or other
abnormality of the extensor apparatus.
Test for ligament stability

Collateral ligament
With full extend knee hold the pt ankle in
between examiner 2 elbow
Then with both hand attempt to abduct and
adduct the tibia while keep the knee straight
patient will feel pain in effect ligament
Flex the patient's knee to 90 and

maintain this position by sitting with your thigh
trapping the patient's foot
With your hands behind the upper tibia and
both thumbs over the tibial tuberosity, pull the
tibia anteriorly
o If there is significant movement
(compare with the opposite knee) the
anterior cruciate ligament is lax,
Now push backwards on the tibia.
o Posterior movement of the tibia suggests
posterior cruciate ligament laxity.
MKS 138
Define arthralgia , arthritis , and myalgia ?
Arthralgia
o Pain in a joint is called arthralgia
Myalgia
o Pain in a muscle is called myalgia
Arthritis :
o Pain and swelling of the joint
Define with example mono,oligo and poly arthritis ?
Monoarthritis (single joint involvement)

Oligoarthritis (involvement of two to four joints)
Polyarthritis (involvement of five or more joints)
Cause of mono arthritis Cause of oligoarthritis Causes of poly arthritis

Seronegative conditions:
To remember TSH & GP Rheumatoid arthritis,
TB
ankylosing spondylitis Systemic lupus
enteropathic arthritis erythematosus
Trauma reactive arthritis
Rheumatic fever
Septic arthtitis psoriatic arthropathy
Viral arthritis
Haemarthrosis in
haemophilia degenerative / non-
inflammatory
Gout or
pseudogout osteoarthritis
How will u differentiate from mechanical pain from arthritic pain?
Mechanical pain Inflammatory pain

Relation with rest More on activity and relieve on More on rest relieve on activity
rest
Morning stiffness Absent Present
Onset Sudden Gradual
Systemic feature Fever ---absent Present
ESR Normal Increased
What do u mean by GALS screen ?

The GALS screen consists of 4 components:
G = Gait.
A = Arms.
L = Legs.
S = Spine.
MKS 139
Spondylosis: degenerative change in the spine.
Retrolisthesis: the posterior slip of one vertebra on Spondylolisthesis: the anterior slip of one vertebra
an inferior vertebra. on an inferior vertebra (fig A)
Spondylitis : inflammation of spine Spondylolysis: defect in the pars interarticularis of a

vertebral arch (fig B)
crrosponding vertrebral Spinal cord

body segment
Cervical Add 1
Upper thoracic T1+T6 Add 2
T7-----T9 --vertebra --------------------add 3
T10---------- vertebra --------L1-2 cord
T11------- vertebra -------L3-4 cord
T12 ------- vertebra ------------L5 cord
L1 --------- vertebra---- sacral and coccy
MKS 140
Examination of thyroid gland
Examination of thyroid gland composed of

Inspection
Palpation
Auscultation
Percussion
Then do thyroid status test
Eye face
Hand
Ankle jerk and edema
Proximal myopathy
Introduction
1st give salaam the patient.
Introduced your self to the patient and explained the what exam you want to do and take consent of the
patient for examination .
Why thyroid gland move up ?
Expose the neck
Inspection As thyroid gland is enveloped in
the pretracheal fascia which is
Look at the patient s neck for the following attached to the cricoid cartilage
Thyroid gland is visible or not that why it move up ward with
Scars mark present or not. swallow ?
Enlarged cervical lymph nodes
Any engorged neck vein present or not
o Then ask the patient to swallow and
o you look that any lump (thyroid gland ) is moving with swallowing or not
o If it is move upward with swallow then it is thyroid gland .
o Then ask the patient to protrude tongue? Why is it not lymph node?
(do only when thryroid gland is visible ) As because lymph node not move
o If it is thyroglossal cyst then it will retract inward with respiration
o
Now go for palpation.

Go behind the patient and palpate the gland with the finger of both hand and tell the patient to
swallow and u palpate the gland moving during swallowing .
Then again u palpate the whole gland and do not forget to palpate the margin of both lobe and also
isthmus with finger .
At that time of palpation pl look for
o Size
o Surface
o Consistency
o Tenderness
o Fixed with underlying structure and overlying skin
o Palpate the lower margin of the gland
Other part of palpation

o Palpate the cervical lymph node
o Feel the carotid pulse
o Trachea deviation due to retro sternal extension
Thyroid Examination 141
Then Auscultation
Please Auscultate over neck gland with bell of stethoscope to see any bruit present of not
Then percussion (u can do it from front )
o Percussion over the sternum from downward to upward for retro sternal extension
Now see the

Pemberton's sign
o Ask the patient to raise his arms above the head,
o If the patient have retro-sternal extension of the goiter
o The patient may develop signs of compressim,Such as
Suffusion of the face,
Syncope or
Giddiness
Now if you find that thyroid gland is enlarge then u ask the examiner that I want to do some
relevant examination to see the thyroid status of the this .
If the examiner asks u what you want to see . then say I want to see
o Appear (face )
o Eye sign
o Hand
o Ankle jerk and leg for pre tibial myxedema
o Proximal myopathy
Hand
o First ask the patient to out stretch the hand with finger spread out and u look for fine tremor for better
see u may give paper over hand
o Then hand shakes with patient to see warm sweaty hand
o Look the palmer surface of hand to see palmer erythma
o Pulse for tachycardia or atrial fibrillation.
o Look for Clubbing or thyroid Acropachy (press the lower end of radius and ulna, if pt complained
pain then it is thyroid acropachy)
Eye
In eye u look for
- Exophthalmos.
- Lid lag.
- Lid retraction (sclera visible above the cornea).
- Extraocular movements.
-.
lid lag
Hold ur index finger above patients head and ask the patient to follow your finger and then move
it down ward up to a point below the nose and observe patient eye globe and lids movement
Normally Eye globe and Eye lid move simultaneously

in lid lag ---- move-ment of the lid lags behind that of the globe that means u see that eye globe goes
downward first then eye lids comes down ward---- this is von Graefe's sign.
Lid retraction ;
o Ask the patient to look forward and u try to see visible sclera above the margin of cornea
o Normally eyelid enclose 1/5 of sclera so u cannot see the sclera above cornea
o Lid retraction : when the sclera above the upper limbus of the cornea will be
Seen then it will be called lid retraction . This is Dalrymple's sign
Exophthalmus
o Look patient eye from behind to confirm proptosis in which eye ball may visible above the supra
orbital ridge.
o In normal patient if u look above the supra orbital ridge u can see the zigomatic arch but in case of
proptosis u can not see it eye ball will come in between them and u cannot see the zigomatic arch .
o Card test :
o If u place a card paper between supra orbital ridge and maxillary prominence it will not touch the
cornea or sclera normally. In case of exophthalmus it touch the sclera or eye comes in between
them.
See Eye movement
Lower limbs: examination
Examine the shins for pretibial myxoedema (bilateral pinkish brown dermal plaques).
Test for Proximal myopathy

Lower limb
Ask patient to stand from squatting position
Patient can not do it in case proximal myopathy
Upper limb
Ask the patient rise his arm above his shoulder while u giving pressure over his arm
Test for with hyper-refiexia./ or

See the knee jerk only in sitting position keeping the leg in suspending position.
Delayed relaxation ankle jerk
Ask the patient to sit in knee down position keeping the leg and ankle behind the coach or bed and
See ankle jerk for delayed relaxation and
Also u sees the face of the patient and talk with patient
By talking husky voice in hypothyroidism

Face in hypothyroidism
Puffy face with baggy eyelid, loss of lateral 1/3 of eye brows . immobile and uninterested face
Face in hyperthyroidism
Anxious, frightened / fidgety facies with staring look
Ask for dysphagia and dyspnea --- retro sternal goiter

Question related to thyroid gland:
When bruit found?

It found in hyperthyroidism
Why found?
This is found due to abnormally high blood flow thyroid gland
How will u differentiate it from the carotid bruit and venous hum?
Carotid bruitwill be louder along the line of the carotid artery
Thyroid bruit usually bilateral and found whole over gland
Venous hump a gentle pressure over the root of the neck will diminish the intensity of venous
hump.
How will u differentiate between tremor or sweating of anxiety neurosis and hyperthyroidism ?
o In anxiety neurosis the tremor and sweaty with cold clammy hand
o In thyrotoxicosis there fine tremor with warm sweaty hand
What will sure that this tachycardia is due to thyrotoxicosis or anxiety?

o In thyrotoxicosis ---tachycardia present at sleep but
o In anxiety ---it does not present in sleep.
How surface help in identification different type of thyroid disease
Surface and consistency

Diffuse goiter, soft in consistency with Graves
bruit
Diffuse and firm Hashismotos thyroiditis
Diffuse and tender Subacute thyroiditis
Multiple nodular Multinodular goiter
Toxic nodular goiter Solitary nodule

Hard nodular Malignancy
Smooth surface

Now description after examination
Examination of thyroid gland of this young cachetic patient reveals that thyroid gland is diffusely
enlarged 5 cm X 4 cm, non tender , firm /soft / hard in consistency , freely mobile ,no bruit , no
retrosternal extenstion , no palpable lymph node and carotid pulse is present .
Sign of toxicity like exophthalmus , lid lag and lid retraction , tremor on outstretch hand , warm sweaty
hand , pulse is 110 / min regular , jerk are exaggerated and pretibial myxedema absent . No feature of
proximal myopathy
in case of multinodular goiter

Examination of thyroid gland of this middle age patient reveals that thyroid gland is enlarged right
lobe larger then the left lobe . surface is irregular containing multiple nodule of variable size and shape
largest of them is 3X2 cm , non tender , firm /soft / hard in consistency , freely mobile ,no bruit , no
retrosternal extenstion , no palpable lymph node and carotid pulse is present .
The patient has not any Sign of toxicity like exophthalmus , lid lag , lid retraction , tachycardia , warm
sweaty hand, pretibitial myxedema . Reflexs are normal
In case of solitary nodule
Examination of thyroid gland of this middle age patient reveals that thyroid gland is enlarge . there is
solitary nodule in the right or left lobe measuring 2X1.5 cm , surface is smooth , non tender , firm /soft /
hard in consistency , freely mobile ,no bruit , no retrosternal extenstion , no palpable lymph node and
carotid pulse is present .
There are no sign of toxicity
How would you grade the size of the goitre?

How would you grade the size of the goitre?
WHO grading of goitre
Grade 0: No palpable or visible goitre.

Grade 1: Palpable goitre (larger than terminal phalanges of examiner's thumbs).
lA Goitre detectable only on pt lpation.
lB Goitre palpable and visible with neck extended.
Grade 2: Goitre visible with neck in normal position.
Grade 3: Large goitre visible from a distanc
What is the significance of the thyroid bruit?

The thyroid bruit is almost pathognomonic of Graves' disease and occurs only

What investigation u want to do in patient with enlarge thyroid
Thyroid hormone test
T3 ,T4 , TSH ----(free T3 ,T4)
Thyroid scan and Radioiodine uptake
USG OF thyroid gland
FNAC of thyroid gland
Thyroid receptor antibody
TSH T4 T3 Most likely interpretation(s)

Undetectable Raised Raised Primary thyrotoxicosis
Undetectable Normal1 Raised Primary T3-toxicosis
Undetectable Normal (upper part of Normal( upper part of Subclinical thyrotoxicosis
reference range )1 reference range )1
Undetectable Low Low Secondary hypothyroidism
i.e. pituitary or hypothalamic
disease
Elevated > 20 mU/l Low Low3 Primary hypothyroidism
Mildly elevated 5-20 mU/l Normal (lower part of Normal( lower part of Subclinical hypothyroidism
reference range) reference range)

Short Cases of Medicine

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Short Cases of Medicine

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SHORT CASES

1. SIZE AND SHAPE OF CHEST WALL

Cause of unilateral restriction

3. MOVEMENT OF THE CHEST

4. RESPIRATORY RATE AND RHYMTH, PATTERN OF BREATHING

What are the abnormal patterns of breathing such as :

Cause of tachypnoea Physiological

Palpation of the chest

At the middle zone

o Now goes to mid axillary line :

How will u do percussion?

Like vocal fremitus percussion is done in three lines

In auscultation we the following :

BREATH SOUND AND ADD SOUND IS LISTEN SIMULTANEOUSLY

First along Mid clavicular :

Vocal resonance : Auscultatory equivalent of vocal fremitus.

All the procedures are same as listening breath sound

At the middle zone

SEE THE VOCAL FREMITUS

Now start see vocal fremitus in following ways

How will u see the Basal crep (++):

Interpretation of percussions note:

Resonance Over normal chest

Dull Woody dull---consolidation

Type of breath sound

What is normal breath sound ?

Cause of decreased sound

Vesicular breath sound with Usually pathological Cause

What are the cause of localized rhochi :

Name the condition where creps disappear after coughing?

When best heard:

Pleural rub Creps

How will u differentiate between pleural rub and pericardial rub?

Pleural rub Pericardial rub

Increased vocal resonance Diminish vocal resonance

Inspection Restriction of movement of right

Consolidation (right upper ZONE)

Inspection Restriction of movement of right upper chest

Palpation Trachea is in central

Auscultation Breath sound is bronchial &

Peripheral collapse (with patent bronchus ) right upper Zone

Inspection Restriction of movement of right upper chest

Palpation Trachea is deviated to the right

Auscultation Breath sound is bronchial &

Inspection Restriction of movement of right upper chest

Palpation Trachea is deviated to the right

Auscultation Breath sound is absent or diminish &

Fibrosis of Right upper Zone

Inspection Restriction of movement of right upper chest

Auscultation Breath sound is bronchial &

Right sided Pneumothorax

Inspection Restriction of movement of right side of chest

Palpation Trachea is deviated to the left

Auscultation Breath sound is absent or diminish &

How will you describe after respiratory system examination:

So my clinical diagnosis is fibrosis of right upper chest

A short case ----right sided pleural effusion

My clinical diagnosis ----right sided pleural effusion

Why u called it pleural effusion?

Why this not a case of collapse

What may be the cause of pleural effusion in this patient

What r the cause of epigastric Cause of suprasternal pulsation

First we will see the apex beat

1. First keep the measuring tap on the bed from