BSc Clinical Methods I

DR F DERY
CHIEF MEDICAL OFFICER
 Outline

• Introduction to Clinical Methods 4-6

• History taking 7-41
- Adults 7-37
- Children 38-41
• Physical examination 42-180
- Introduction to Physical Examination 42-48
- General examination 49-70
- Respiratory System 71-101
- Cardiovascular System 102-126
- Gastro-intestinal System 128-162
- Integumentary System 163-184
• Skills lab(Practical)- techniques of Physical
Examination 185-196
- General examination 185-187
- Respiratory System 188-190
- Cardiovascular System 191-193
- Abdomen(GIT) 194-196
 Introduction

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

A
symptom is a phenomenon that is experienced by the individual affected
by the disease- subjective evidence of disease.
A sign is a phenomenon that can be detected by someone other than the
individual affected by the disease- objective evidence of disease.
Clinical features- a group of physical signs or symptoms associated with a
particular morbid process, the interpretation of which leads to a specific
diagnosis
Medical diagnosis is the process of determining which disease or condition
explains a person’s symptoms and signs and when necessary, results of
investigations.
Differential diagnosis are various other diseases or conditions which share
signs and/or symptoms of the diagnosis.
 Making a Diagnosis

Diagnosis should precede treatment whenever

possible. There are 2 steps in making diagnosis:
1. Observation by clinical methods:
• History taking- chat with patient on his/her medical problems
• Physical examination- using tools available at your disposal
• Ancillary investigations- lab, diagnostic imaging
2. Interpretation of the information obtained- what
disease condition you can make out of the information in 1
 Investigations

• They are:
- Laboratory investigations- blood, stool, urine, sputum, body fluids, etc
- Diagnostic imaging- x-rays, ultrasonography, CT scan, MRI, etc
• Investigations help:
- Confirm a suspected diagnosis
- Exclude something important
- Define the extent of a disease
- Monitor the progress of a disease
• Only do a test/investigation if the result will influence management of
the disease
• If there is disparity , trust clinical judgment and repeat the test
• Request an investigation if you can interpret the results
 History Taking (Adult)

The medical history is an account of all medical events and

problems the person has experienced bearing on their
health past, present and future.
By the end of the history taking you should have a good
idea as to a diagnosis or have several differential diagnosis
in mind. The physical examination is the chance to confirm
or refute these. It is usual to record the findings of the
history taken under the following headings (Format):
• Presenting Complaint(s) (PC)
• History of Presenting Complaint (HPC)
• On Direct Questioning (ODQ)
Review of system(s) involved in the presenting complaint
• Review of other systems (ROS)/Systemic Enquiry (SE)
• Past Medical History (PMH)
• Drug and Allergy History (D&AH)
• Family History (FH)
• Reproductive (RH)/Obstetric and Gynecological History
(O&GH)- any woman of reproductive age
• Immunization History (IH)- in children
• Social and Occupational History (SH)
• Psychological assessment
• Summary of the History taken
• Diagnosis and differential diagnosis
• Suggested Investigations
History Taking
1. Introduction
Put the patient at ease. Use the pneumonic WIIPP

• Wash your hands/sanitize hands

• Introduce yourself: name, job
• Identify patient with his/her : name, age, occupation
• Permission: reason for seeing the patient and consent
• Positioning: sit same level of patient and not behind a desk
 History Taking

2. Presenting complaint (PC)- reason for the encounter

• Ask patient to describe their problem using open questions (eg what
brought you to the hospital?)
• The trouble recently (chief symptom); present as list if several
symptoms
• Record the patient own words
• Do not interrupt the patient first few sentences if possible
3. History of Presenting Complaint (HPC)- determining the nature of the
complaint
Ask the patient further questions (opened and closed) about the PC into
detail using the alphabets OPQRST for complaints other than pain
- O- Onset- date, sudden/gradual
- P- Provocation/palliation (exacerbation/relieving factors)- things that
make problem better or worse
- Q- Quality- intermittent, constant
- R- Region and radiation- where, and whether moves to any other
area
- S- Severity- scale of 1-10
- Time (history)- how long the condition has been going on and how
it has changed with time (better, worse, different symptoms)
Use the pneumonic SOCRATES if complaint is pain
- Site- where the pain is worse. Use 1 finger to point to the site
- Onset- when did it start? Date, time. Was it gradual or sudden,
constant or intermittent?
- Character- what is the pain like- dull, aching, stubbing, burning,
etc
- Radiation- does the pain move anywhere else or stay in one place
- Associated symptoms- is there anything else associated with
the pain? Vomiting, sweating, nausea, shortness of breath
- Time course- does it follow any time course?
- Exacerbating/relieving factors- what makes it worse or better?
- Severity- scored out of 10, with 10 as the worst pain
4. On Direct Questioning (ODQ)
• Ask specific questions about the systems you have in
mind/systems involved from the history of presenting
complaints(HPC)
• Review of the relevant systems with similar symptom(s) eg
cough is in CVS and RS. Ask questions on both
5. Systemic Enquiry/Functional enquiry/Review of Systems
A brief screen of all the other systems of the body which the
patient might have forgotten about and not covered in the HPC
and DQ. Ask the patient about the following symptoms in the
other systems:
- General symptoms- weight loss/gain, appetite loss/gain, fever,
malaise
- Respiratoy symptoms- cough, sputum production, hemoptysis,
shortness of breath, wheeze, chest pain
- Cardiovascular symptoms- shortness of breath on exertion,
paroxysmal nocturnal dyspnea, chest pain, palpitations, ankle
swelling, orthopnea, claudication
- Gastrointestinal symptoms- indigestion (dyspepsia or
stomach upset), abdominal pain, nausea, vomiting,
diarrhea, constipation, dysphagia, heart burns,
hematemesis, malaena stools
- Genito-urinary- urine frequency, polyuria, dysuria,
hematuria, nocturia, menstrual problems, impotence,
discharge
- Neurological- headaches, dizziness, tingling, weakness,
tremors, fits, faints, blackouts, numbness
- Locomotor symptoms- aches, pains, stiffness, swelling
- Skin symptoms- lumps, ulcers, rashes, itch
- Obstetrics/gynecology- menses (menarche, last
menstrual period), periods (duration, cycle,
regularity, pain), contraception, gravity/parity,
children (age of last child, birth weight),
complications of pregnancies, labor and puerperium,
miscarriages, terminations
6. Past Medical History (PMH)- significant past illnesses
Ask patient about all previous medical problems using
the pneumonic. (MR DJ THE CAS)
Myocardial infarction
Jaundice
Tuberculosis
Hypertension
Rheumatic fever
Epilepsy
Asthma
Diabetes
Stroke
Cancer
For operations ask about any previous anesthetic problems
(MR DJ THE CAS)
7. Drug History (D&AH)- now and past, prescribed and
OTC
• All medications including herbal medications that they
take: dose, frequency, route and compliance
• Allergies-reaction to medicines/herbs, history of
anaphylaxis
8. Social History (SH)
• His social class, race, religion, marital status
• His occupation- what his work involves that exposes
him to pathogens eg asbestos
• Recreational drugs and hobbies
• Tobacco use- attempt to quantify in pack-years (number of
packs of 20 cigarettes smoked per day x number of years
smoking)
• Alcohol intake- number of units/week
Recommended daily intake of 3-4 units for men and 2-3 units
for women with 2 alcohol free days per week.
• Home situation- accommodation type (house, bungalow,
single room), any carers, pets, water, sanitary conditions,
able to wash, cook or dress, mobility aids, family support
• Travel history- recent travel
9. Family History- gather some disease information
about the patient’s family
• Heart disease, cancers
• HPT, TB, DM, genetic conditions
• Deaths and at what age?
10. Obstetric/gynecological history if a female-
menses(cycle, pain, duration, volume), menarche,
deliveries & outcome, FP
11. Immunization history if a child- all the antigens
(collect weighing card of child and ascertain the immunization status)
12. SUMMARY
• Provide a short summary of the history
- Name, age
- Presenting complaints
- Relevant medical history
• Give a diagnosis and differential diagnosis
• Explain a brief investigation
As a beginner you need to follow the headings of the history
taking but as you gain experience you will know in a given case
which part of the history is particularly worth persuing.
Examples:
• If a patient has chest symptoms, the fact that he worked with
asbestos factory may be a vital clue , so you will stress more on
occupational history
• If the patient complains are those of anemia, the fact that he
has been treated with chloramphenicol may be important, so
you stress on drug history
• A white man with fever, the fact that he travelled to West
Africa may be a clue. Stress on social history
 When you start with history taking it is wise to make
at least some enquiry under all the headings listed in
the format. When you get more experience you can
know which headings to concentrate on. But in a
difficult case it would be unwise to neglect any of the
headings listed.
 Example of History Taking
Kofi: 30yrs, 60kg, BP110/70, pulse 95/min, RR 24/min, T 38.5

• PC- cough and chest pain all of 3 days duration

• HPC- Kofi was apparently well until 3 days ago(onset) he developed a sudden
(onset) cough productive of rusty sputum. The cough was throughout both day
and night(time course) with no exacerbation or relieving factors. The cough was
getting worse (change over time) so he decided to visit the hospital.
The cough was associated with pain which started the same day on the right side
of the chest(site) and stabbing in character with a severity score of 7/10. Pain
made worse by coughing and relieved at rest. The pain did not radiate anywhere
and no associated symptoms
• ODQ- (Note that cough and chest pain are symptoms of respiratory and
cardiovascular), so ask questions on both (slide 12)
- Respiratory- cough productive of rusty sputum, short of breath, no wheezing
and no hemoptysis (slide 13)
- Cardiovascular- No orthopnea, no shortness of breath on exertion, no
paroxysmal nocturnal dyspnea or ankle edema (slide 13)
 (Note that all questions were negative for CVS, so you have
excluded CVS as the cause of cough and chest pain). His
cough and chest pain is solely from the respiratory system
• Systemic/Functional Enquiry- there was fever. All other
systems were of no significance (slide 13).
• PMHx- nil of significance (slide 15, 16)
• Drug& allergy Hx- taken paracetamol since the onset of the
illness 1gm tid and mist expect sed 1 tablespoon tid since
onset of illness. He has also taken athemeter/lumefantrine
(80/480) 1 twice a day for 3 days. Never had any allergy to
any medication/herbs in the past (slide 17)
• Social Hx- he is a subsistent farmer, single, takes the local gin ½ a
bottle every evening before meals for the past 5 years. Stays in a
farm hut near a valley and sleeps on a floor mat (slide 17, 18).
• FHx- nil of significance (slide 19)
• Psychological assessment- well oriented in place , person and time
• Summary (all positive and important negative findings)
In summary, I present to you Kofi , a 30 year old subsistent farmer
with T= 38.5,P= 95 RR= 24/min, BP= 110/70 and weighing 60kg who
presented with a complain of cough, chest pain of 3 days duration. Kofi
was apparently well until 3 days ago he developed a sudden onset of
cough productive of rusty sputum associated with right chest pain ,
stabbing in character and worse by coughing with pain severity of
7/10.
 Kofi was short of breath and not wheezing and no hemoptysis with negative CVS
symptoms.
Systemic review revealed headaches and fever. He had
taken paracetamol and anti- malarial with no effect and no known drug/herbal allergy.
He is a chronic
alcoholic and his living condition exposes him to cold situations (sleeps near valley on
floor mat)
NB In this case all the positives and important negatives are pointing towards a
Respiratory System condition on the right. You are therefore drawing near a diagnosis
or provisional diagnosis of a lung/respiratory disease on the right side of the chest.
If you
now add your physical examination and if necessary your investigations you can arrive
at a final diagnosis.

To be continued after physical examination of the respiratory system

 Focused History Taking

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

of present illness, and attempting to collect all related details
(solely to the complaint) in other parts of the history.
Usually such focused history is required when seeing
patients in the OPD or in an emergency department.
Format of Focused History
• PC
• HPC
• ODQ
• Systemic Review/Enquiry- only systems involved in the PC
• Complained-directed review of other steps (PMH, DH,FH, O&G,
Immunization, Social) ie only those steps relevant to the complaint

Focused History Taking

1. PC- Clarify reason for the visit
2. HPC- Basic information to gather on complaint- SOCRATES for
pain, OPQRST for other complaint
- O- Onset- date, sudden/gradual
- P- Provocation/palliation (exacerbation/relieving)- things that make
problem better or worse
- Q- Quality (if pain- sharp, dull, crushing, burning), (if other-
intermittent, constant)
- R- Region and radiation- if pain, where pain is and whether
moves to any other area
- S- Severity- scale of 1-10
- Time (history of changes with time)- how long the
condition has been going on and how it has changed
(better, worse, different symptoms)
3. Review of Systems/Systemic Enquiry- Focused review of
systems- review of systems involved in the complaint
Example- chest pain- the following systems give chest pain-
CVS, RS, GIT (heart burns, GERD). Review these systems in
chest pain
4. Review of other steps in history taking (PMH,
DH,FH,O&G, Social, Immunization, Psychological)-
Complaint-directed review of the other steps in history
taking (might not have to go through all the steps
depending on the complaint)
5. Summary of history
6. Diagnosis and Differential diagnosis
7. Suggested investigations
 Example of Focused History Taking using a simulated patient
Akua: 40yrs, 65kg, BP170/110, pulse 80/min, RR 34/min, T 36.5
who complains of breathlessness

Information to simulated patient

• Complaint- breathlessness or I am breathless
• Onset- started gradually
• Worse- lying flat and on exertion
• Better- when sitting up at rest
• Progression- intermittent (on and off)
• Severity- cannot breathe on lying down and on little exertion
• Time course- 3 months and now getting worse
• Cough producing sputum like foam with streaks of blood,
wheezing and wake up at night breathless
• Past illnesses- was told I had hypertension 1 year ago
• Family members with disease- my grandmother has hypertension
and died 5 years ago
• Medications taken- Hypertension pills but stopped 3 months ago.
No allergy
NB: All other questions should be answered negative apart from
the above

Focused History On this Patient with Breathlessness

• Introduces him/herself appropriately
• Obtains verbal consent
• PC (Clarify reason for visit)
Student- what is your complaint?
• HPC (OPQRST)
Student- how did it start?(O), what makes it worse?, what makes
it better? (P)
Student-is the breathlessness throughout or on and off ? (Q)
NB: (R= region and radiation) is not relevant here
Student- how severe is your condition?(S)
Student- how long has it been going on and any change with
time?(T)
• Focused review of systems
NB: breathlessness is both a CVS and RS complaint, so you review
these 2 systems
Student- do you cough? do you produce sputum, and what
color?
Student- do you have a wheeze? Do you wake up in the night
breathless? Do you have swollen feet?
• Other steps in history taking (PMH, FH, D&AH, O&GH, IH)
relevant to the complaint
- PMH, FH, D&AH are relevant in this case.
- O&GH and IH not relevant in this case
Student- any past history of heart related problems? (PMH)
Student- any family member with any heart related problem?
(FH)
Student- have you taken any medications and any allergy to
medications? (DH & Allergy)
• Summary- all positives and important negatives
In summary I present Akua aged 40 years, weighing 65kg with BP
170/110 and RR 30 who complained of breathlessness of gradual
onset; worse lying down and better sitting. This situation was on
and off for 3 months until it became worse even at rest. Akua
coughs with foamy blood stained sputum. There was orthopnea,
and no pedal edema. She is a known hypertensive who defaulted
treatment for 3 months and the grandmother died of hypertension
5 years ago. She has no allergy to medications
My provisional diagnosis is hypertensive left heart failure
Differentials: asthma, pulmonary embolism, bronchiectasis, COPD
Suggested investigations: chest x-ray, ECG
 CHECT LIST
• Introduces him/herself appropriately- 2
• Obtains verbal consent- 2
• Clarifies the reason for the visit PC(main complaint)- 2
• Obtains history of breathlessness (OPQRST)
- How did it start (O) - 2
- What makes it worse or better (P)-2
- Progress with time (Q) - 2
- R (not applicable)
- How severe is it? (S)-2
- Change of breathlessness with Time (T)-2
• Focused review of systems involved in breathlessness
- Review RS (cough, wheeze, sputum and color) - 2
- Review CVS (orthopnea, paroxysmal nocturnal dyspnea, edema of feet) – 2
• Past medical History 2
• Family History 2
• Medication and allergy history 2
• Summary of history
- Positives of the suspected condition- 3
- Important negatives- 2
• Provisional diagnosis/differentials 2
• Suggested Investigations 2
TOTAL= 35
 History Taking (Pediatrics)

• Put child at ease by:

- Compliment their clothes or show an interesting toy
- Tell child your name and ask theirs
- Ask what they had for breakfast
- Shake hands with them
• Talk to the parents
Ask for the infant record book- contains information about weight,
immunization, development and illnesses in first few years of life
• Presenting complaint (PC)
• History of presenting complaint (HPC)
• On direct questioning (ODQ)
• Birth history
- Place of birth
- Gestation and pregnancy
- Birth weight
- Delivery
- Perinatal events
• Feeding methods
• Past medical history (PMH)
• Developmental history
Check the child’s age and ask for the corresponding gross motor
activities:
Age Gross Motor
- 3 months head control, pushes up with arms
- 6 months sits
- 9 months crawls, pulls to stand
- 12 months walks
- 18 months walks up stairs, jumps
- 2 years kicks, runs
- 4 years stands on one leg, hops
- 5 years can ride a bicycle
• Immunizations (IH)- check infant record book
• Drugs and allergies (D&AH)
• Family tree- sibling’s ages, deaths, etc

• Parental age and occupation

• Family illnesses (FH)
• Social History (SH)
- Housing
- Travel
• Systemic review (ROS)
 Physical Examination

Physical examination is the evaluation of the body to

determine its state of health
The techniques (format)include the
following in each system examination:
• Inspection (looking with your eyes)
• Palpation (feeling with fingers/palm)
• Percussion (tapping with middle finger)
• Auscultation (listening with stethoscope)
The format might change depending on the
condition you are dealing with.
Before commencing a physical examination:
• Always stand at the patient right hand side
• Introduce yourself to the patient
• Explain what you would like to do
• Obtain a verbal consent
• Ensure patient has adequate privacy to undress
• Make sure you will not be disturbed
• Position the patient in supine position with head and
shoulders raised at 45 degrees(ie put a pillow behind
the shoulders).
 Physical Examination Instruments/Devices

• Thermometer- for measuring temperature

• Sphygmomanometer- for measuring blood pressure
• Stethoscope- for listening to body sounds- heart, lungs,
thyroid, intestines as well as flow in arteries and veins
• Otoscope- to view ear canal and tympanic membrane
• Ophthalmoscope- to examine the interior structures of
the eye
• Percussion(patella) hammer- used to test neurologic
reflexes
• Disposable/safety pin- for pain sensation
• Brush/cotton wisp or microfilament- light touch sensation
• Penlight- provides light to examine specific area of the body
• Nasal speculum- for inspection of the lining of the nose,
nasal membranes and septum
• Laryngeal mirror- to examine larynx and other areas of the
throat
• Audioscope- used to screen for hearing loss
• Tuning fork- to test patient hearing and vibration sense
• The examiner’s hand( for methods of palpation)
- Finger tips- for skin texture(smooth, rough), swelling,
pulsations
- Fingers and thumb (grasping action)- to determine
position, size and consistency of body part
- Front of the fingers- for light palpation, deep palpation,
light ballottement and deep ballottement
- Back of fingers and hand-to check body temperature
- Side of hand (palmar)- to check vibrations in the body-
vocal fremitus (vibration of sound), fluid thrill (vibration of
fluid in abdomen), heart thrill (vibrations of the valves)
 Areas that are Commonly Auscultated
• Respiratory system (lungs)- listen for normal breath sounds
and abnormal breath sounds
• Heart- listen for normal and abnormal heart sounds
(murmurs)- caused by turbulent blood flow through the
heart valves
• Abdomen- listen for normal and abnormal bowel sounds
• Major vessels (carotid artery, abdominal aorta, renal
artery)- for bruits (an audible vascular sound associated
with turbulent blood flow)
• Thyroid gland- for bruits
 Physical Examination

Order For Routine Physical Examination

• General examination
• Systemic examination
- Cardiovascular system
- Respiratory system
-
Gastrointestinal/genitourinary (The abdomen) system
- Neurological
(nervous) system
- Endocrine system
- Musculoskeletal system
-
Integumentary (skin and appendages) system
 Do a General Examination
This cuts across all Systems

To begin, use the acronym WIIPPPPE

Wash your hands/sanitize hands
Introduce yourself
Identity of patient (confirm)
Permission (consent and explain examination)
Pain (any pain)
Position patient at 45 degrees (pillow behind
shoulders)
Privacy
Expose chest to waist
Usually you stand at the foot end of the bed
• Behavior- oriented in place, person and time
• How sick is he/she? Well or in extremis?
• Is he in pain? Does it make him lie still (peritonitis) or writhe about
(colic)
Peritonitis= inflammation of the tissue that lines the abdomen
(peritoneum)
Colic= pain that comes and goes and that intensifies and then
gradually ceases
• Pattern of breathing
- Kussmaul (deep, rapid breathing)- DKA, organ failure, seizures, toxin
ingestion
- Cheyne stokes (alternating periods of cessation of respiration &
hyperventilation)-heart failure, stroke, brain tumors
• Shape-obese, cachetic
The body mass index (BMI) is a useful estimate for body fatness
BMI = Weight (kg)/[height (m)] square
The BMI is classified as follows:
- 19-25 = normal
- 25-30 = overweight
- 30-40 = obese
- > 40 = extreme or morbid obesity
• Pedal swelling
- pitting- press gently on both legs above the medial
malleoli with both thumbs for a while and see if a
dent- severe cardiac/renal failure, nephrotic
syndrome, severe malnutrition
- Non-pitting- lymphedema
• Look for varicose veins (dilated engorged veins in the
legs)
Then move up and hold the hand
• Warm, sweaty hands- hyperthyroidism.
Cold, moist hands-anxiety
• Reluctance to let go your hand-loneliness
• Palmar erythema (reddish base of palms)- cirrhosis of
liver, pregnancy, polycythemia
• Dupuytren’s contracture (fibrosis and contracture of
palmar fascia)- liver disease, epilepsy, trauma, ageing
• Check for palmar pallor (palmar skin creases color)-
compare yours with the patient) and state no pallor,
some pallor or severe pallor- anemia, emotional shock
• Hydration status (dehydration)
- Skin turgor- pinch back of hand & see if the skin goes back
slowly/very slowly- dehydration or lack of connective
tissue support in ageing
Signs of dehydration in general
- Skin turgor
- Mucous membranes- mouth and tongue dry
- Capillary refill- press on pulp of thumb at level of the heart
for 5sec and then release. If it takes more than 2 sec for
the pink color to return is an indication of poor blood
supply to the peripheries
- Compensatory tachycardia (increase pulse rate) in
dehydration
- BP low on standing suggest dehydration
- JVP is low in dehydration
• Check for peripheral cyanosis- see if the finger nails are
bluish- vasoconstriction and peripheral vascular disease,
reduced cardiac output, exposure to cold
• Check for choilonykia (spoon shaped nails)-iron deficiency
anemia
• Nail destruction (onycholysis)- hyperthyroidism, fungal nail
infection, psoriasis
• Splinter hemorrhages (fine longitudinal bleeds under nails)-
infective endocarditis in a febrile patient
• Check for clubbing- lung abscess/cancer, COPD; infective
endocarditis, congenital heart disease; liver
cirrhosis/cancer
Two ways:
- Lovibond angle- raise the finger to level of your eye to see
if the angle between the nail & nail bed is obliterated
- Schamroth’s sign-diamond shaped window seen between
opposed nail beds lost
Then move up to the head
• Check and measure JVP (Jugular Venous Pressure)- with
patient lying back with neck exposed and head turn to left.
- Measure the vertical distance from the top of the
pulsation to the sternal angle (Angle of Loius)
- Then add 5cm (this is the distance from the center of the
right atrium to the sternal angle) to give the true JVP
which is 8cm.
- If true JVP is above 8cm it is raised and is due to: Right
ventricular failure, fluid overload, tricuspid
stenosis/regurgitation, pulmonary embolism, superior
vena cava obstruction
Differentiating JVP and Carotid pulsation
JVP Carotid pulsation
- 2 peaks in sinus rhythm 1 peak
- Impalpable palpable
- Obliterated by pressure hard to obliterate
- Moves with respiration little movement
- Hepatojugular reflex rise JVP will not
Hepatojugular reflux- exert pressure over the liver with your
right palm and the JVP will rise by 2cm
• Kussmaul’s sign- JVP rise during inspiration- pericardial
constriction, right ventricular infarction
• Check for jaundice- stabilize the upper eye lid with one finger & let
patient look at the other palm as you move it towards the abdomen
and vice versa. This exposes the white of the eye for you to see if it is
yellow.
- The sign of jaundice is yellow sclera seen in good light.
- hepatitis, hemolysis, chronic liver disease, gall stones
- Yellow skin is unreliable, produced by uremia, carotenemia,
pernicious anemia. Note that in all these cases the sclera is not
yellow
• Check for conjunctiva pallor
• Let patient open mouth and check for:
- central cyanosis(bluish tongue and lips)- COPD,
pulmonary embolism, pneumonia, congenial heart disease
- dehydration(dryness)
- pallor on the protruded tongue
• Palpate for enlarged lymph nodes
- Neck from behind using fingers of both hands-
posterior and anterior triangles, submandibular and
sub-mental regions
- Axillae, inguinal, popliteal. If lymph nodes enlarged
lymphoma, infections (viral-HIV, bacterial-t.b)
• Check vital signs if not already done(temp, BP, pulse,
respiratory rate, blood glucose)
 Vital Signs

• Temperature
- Normal (oral- 36.8; rectal- 37.3; axillary- 36.4)
- Fever- morning temperature >37.3 (oral) or 37.7
(rectal)
- Hypothermia- core temperature <35
- Persistent high temp(pyrexia)- typhoid, halothane
- Intermittent pyrexia-pyogenic infection, lymphoma
- Relapsing pyrexia-Hodgkin’s disease
- Low temperature (hypothermia)- cold exposure (near
drowning), excess alcohol, drug overdose, myxedema
• Pulses palpable
- Radial artery- just medial to the radial styloid process
- Brachial artery- medial side of the antecubital fossa;
medial to the tendinous insertion of the biceps
- Carotid artery- from the larynx laterally backwards
medial to the sternomastoid
- Femoral artery- midway between the pubic tubercle
and the anterior superior iliac spine
- Popliteal artery- centre of popliteal fossa; press with
pressure with tip of fingers
- Posterior tibial artery- posterior and inferior to the
medial malleolus
- Dorsalis pedis artery- superior surface of the foot
between the bases of the 1st and 2nd metatarsals
Express pulse in beats per minute. Count for 1 full
minute and not 30 secs x 2 or 15 secs x 4
Normal rate is 60-90bpm. <60bpm is bradycardia,
>100bpm is tachycardia
age heart rate
<1yr 120-160
1-3yrs 90-140
3-5yrs 75-110
5-12yrs 75-100
12-16yrs 60-90
Check the rhythm- is it regular, regularly irregular,
irregularly irregular
Check the volume
Check the character(waveform)
- Pulsus alternans- alternating strong and weak pulse-
LVF
- Pulsus paradoxus- pulse weaker during inspiration-
cardiac tamponade, status asthmaticus
- Collapsing pulse- suddenly hits your fingers and falls
back quickly- aortic regurgitation
- Pulsus bisferiens- a waveform with 2 peaks- aortic
stenois and regurgitation co-existing
- Radio-femoral delay- the pulses palpated together
and delay in the pulsation reaching the femoral
artery point to coarctation of aorta
- Radio-radial delay point to aneurysm at aortic arch or
subclavian artery stenosis
• Respiratory rate- count the breathing in and the
breathing out as 1 cycle
age respiratory rate
<1yr 30-60
1-3yrs 24-40
3-5yrs 18-30
5-12yrs 18-30
12-16yrs 12-16
- High-asthma, anxiety, lung disease, rising fever
- Low- brainstem problems, heart problems
• Blood Pressure(BP)
- Use the right cuff for the right patient- we have child, standard adult
and large adult cuffs
- Patient should be relaxed
- Monitor the radial pulse and inflate the cuff until the radial pulse is no
more palpable
- Listen over the brachial artery with the diaphragm or bell of the
stethoscope
- Note the point at which the pulsation is audible(korotkoff phase I)-
record as systolic BP
- Note the point at which the sounds disappear(korotkoff phase V)-
record as diastolic BP
- Record the BP as systolic/diastolic
 BP Chart by Age

Age/yrs min. Normal max.

Up to 1 75/50 90/60 110/75
1-5 80/55 95/65 110/79
6-13 90/60 105/70 115/80
14-19 105/73 117/77 120/81
20-24 108/75 120/79 132/83
25-29 109/76 121/80 133/84

30-34 110/77 122/81 134/85

35-39 117/78 123/82 135/86
40-44 112/79 125/83 137/87
45-49 115/80 127/84 138/88
50-54 116/81 129/85 142/89
55-59 118/82 131/86 144/90
60-64 121/83 134/87 147/91

• Pulse pressure- difference between systolic and diastolic

pressures (normal between 40-60)
- Narrow in aortic stenosis, hypovolemia
- Wide in aortic regurgitation, septic shock
 1. Respiratory System

Introduction (Basics)
The respiratory system is a group of organs and tissues that help
us to breathe. It is divided into:
• Upper respiratory tract
- Nose and nasal cavity
- Sinuses
- Pharynx (throat)
- Larynx (voice box) above the vocal cords
• Lower respiratory tract
- Lower part of larynx
- Trachea (wind pipe)
- Bronchi
- Bronchioles (airways)
- Alveoli (air sacs)
- Lungs- right (3 lobes), left (2 lobes)
- Diaphragm- major muscle of respiration
Presenting symptoms
- Cough, dyspnea
- Wheeze, chest pain
- Stridor, fever/night sweats
 Additional History Specific to RS
• Past medical history- BCG vaccination, tuberculosis
• Drug history
- Inhalers used
- Bronchodilators, steroids
- Beta-blockers- can exacerbate COPD
- ACE inhibitors- dry cough
• Family history- asthma, tuberculosis
• Social history
- Occupational exposure- asbestos, cotton
- Alcohol- greater risk of chest infection
- Smoking-quantify
 General Examination
• Respiratory distress- flaring alae nasi, use of accessory
muscles of respiration(platysma, sternocleidomastoid)
• Respiratory rate
• Wheeze, stridor
• Hand
- Tar staining fingers
- Peripheral cyanosis
- Clubbing of fingers
Inspection
Undress to the waist and sit up in bed
• Respiratory rate- how many times the patient breathes in and out
within 1 minute
• Look for Signs of respiratory distress
- Tachypnea
- Nasal flaring
- Tracheal tug- thyroid cartilage pulls towards sternal notch in
inspiration
- Use of accessory muscles of respiration
- Intercostal/subcostal/sternal recession
- Pulsus pardoxus
• Breathing pattern
-kussmaul (slow, deep rapid respiration)- systemic acidosis
-cheyne-stokes (apnea alternating with hyperpnoea)- brainstem
injury, normal in new born babies
-prolonged expiratory phase- asthma, COPD
• Look for chest wall deformities
-pectus carinatum(sternum protruding from chest)- asthma in
childhood, rickets
-pectus excavatum (sternum sunken into chest)- developmental
defect- no significance to pathology
-barrel chest (bulging out of chest wall)- COPD, severe asthma,
normal in children
-kyphosis (hump back)- abnormal anterio-posterior
curvature of spine- aging, osteoporosis, arthritis,
slipped disc
-scoliosis (abnormal lateral curvature of the spine)-
birth defects
- Lordosis (excessive inward curve of spine)-
congenital, osteoporosis
• Observe chest wall movement- decrease movement
indicate lung disease on that side
An objective measure of chest movement is chest
expansion which we will see later
• Check for clubbing- raise the finger to level of your eye
to see if the angle at the base of the nail is lost
(Lovibond angle) OR lost diamond window between
opposed nail beds- back-to-back (Schamroth’s sign)
Stages of Finger Clubbing
- Increase fluctuation of nail bed
- Loss of normal angle between nail bed and cuticle
- Increased longitudinal curvature of nail
- Thickening of whole distal finger
- Shiny and striated appearance of nail and skin
Common Causes of Clubbing
- Respiratory-tuberculosis, bronchiectasis, lung
abscess, lung cancer, pulmonary fibrosis, asbestosis
- Cardiac- cyanotic congenital heart disease, infective
endocarditis
- Liver- cirrhosis, cancer
- GIT- inflammatory bowel disease, cancer
- Endocrine- Graves’ disease
• Examine sputum if available
- Consistently large volumes- bronchiectasis
- Sudden increase in volume- rupture of abscess or
empyema or cyst into a bronchus
- Pink frothy- pulmonary edema/left ventricular failure
- Bloody- malignancy, TB, trauma, pulmonary
embolism
- Yellow/green- infection
- Rusty color- pneumonia
Summary of what to look for on Inspection
• Respiratory rate
• Signs of respiratory distress
• Breathing pattern
• Chest wall deformities
• Chest wall movements
• Finger clubbing
• Sputum if available
 Palpation
• Check for cervical lymphadenopathy standing from behind
with patient sitting
- Place the middle 3 fingers of either hand along the midline
of the neck, just below the chin
- Feel for enlarged lymph nodes in the anterior triangle of
the neck, then the posterior triangle, sub-mental and
submandibular regions
- Note the following features- firm/hard and irregular
(malignant lymph node), tender and rubbery (infection),
matted glands (tuberculosis)
• Trachea position- central or displaced
- Place your index and ring fingers on the prominences
of the sternoclavicular joints
- Use the middle finger of the same hand to trace the
trachea from the voice box to the sternal notch and
note whether it is deviated to the left or right
Displaced to same side of pathology-
lung collapse or fibrosis
Displaced to opposite
side of pathology- effusion or pneumothorax.
• Chest expansion
- Patient to lie flat during the examination
- Put both hands on the patient’s chest, just below the level
of the nipples and anchor the fingers laterally at the sides
- Extend the thumbs so that they touch in the midline
- Ask the patient to take a deep breath and watch the
thumbs move apart equally
Decrease in movement (decrease expansion)- <5cm
on deep inspiration is abnormal- lung fibrosis,
consolidation (pneumonia), effusion, collapse,
pneumothorax
• Test tactile vocal fremitus- ask patient to say 999 whilst
palpating the chest wall with your open palm over different
respiratory segments & comparing both sides. Increase
vocal fremitus(increase vibration)- consolidation
Decrease vocal
fremitus(decrease vibration)- pneumothorax, lung
collapse, pleural effusion, COPD.
• Abnormal masses or sinus tracts- may point to infections
• Areas of tenderness
- Pain areas- between the ribs may indicate inflamed pleura
- Bruises- may indicate fractured rib
Summary of what to palpate for during Palpation
• Cervical lymph nodes
• Trachea position
• Chest expansion
• Tactile vocal fremitus
• Chest masses
• Tender areas of chest
 Percussion
- Place left hand on chest with fingers separated and flat
- Press left middle finger firmly against the chest and strike its middle
phalanx with the flexed right middle finger
- Comparing both sides of the chest step by step
- Percuss directly over the clavicle for the apex of the lungs.
- Percuss symmetrical areas of anterior, posterior & axillary regions.
• Resonance- normal lung sound
• Dullness-collapse, consolidation (pneumonia), fibrosis, tumors. NB cardiac
dullness & liver dullness are normal.
If Resonance over the liver & heart: -
Overexpansion of the lungs eg asthma, emphysema - Bowel
perforation with gas under the diaphragm.
• Stony dullness- pleural effusion
• Hyperresonant- pneumothorax, COPD
Auscultation
Listen with the diaphragm of the stethoscope over symmetrical
areas of the anterior, posterior, & axilla & the bell over the
supraclavicular fossa and comparing both sides of the chest step
by step
Breath sounds
Normal
• Vesicular- rustling quality
Abnormal
• Bronchial(loud, hash and hollow blowing quality)- occur where
lung tissue has become firm or solid eg consolidation, fibrosis
• Diminished- effusions, tumor, pneumonia, lung collapse, COPD,
asthma
• Silent chest- life threatening asthma due to severe bronchospasm
preventing adequate air entry
Added Sounds
• Rhonchi (wheeze heard with stethoscope)- air passing through
narrow airways when patient breathes out eg asthma, COPD.
• Crepitations (crackles). Like dragging a packing case on a floor
-fine & high pitched-pulmonary edema
-coarse & low pitched-pneumonia
• Stridor- harsh sound when patient breathes in- upper airway
obstruction (foreign body, tonsillitis, bronchitis, epiglottitis, croup)
• Vocal resonance (whispering pectoriloquy)- same findings as in
tactile vocal fremitus but using a stethoscope to listen to the 999
• Pleural rub-movement of visceral pleura over parietal pleura
when both surfaces are roughened eg adjacent pneumonia,
pulmonary infarction. Sound like movement of stethoscope
over the chest wall when you listen with a stethoscope
Signs of consolidation (state of lung with alveoli filled with
fluid)
- reduced chest expansion
- dull percussion note
- increased tactile
vocal fremitus & vocal resonance
- bronchial sounds/crepitations
 Some Characteristics of Cough
• Cough with a hoarse voice- laryngitis
• Dry and very painful- tracheitis
• Cough with sharp pain- pleurisy
• Barking- epiglottitis
• Bovine hollow- laryngeal nerve palsy
• Productive and worse on lying flat- left heart failure
• Dry and nauseating and often first thing in the morning-
oesophageal reflux
• Chronic, paroxysmal, worse after exercise and at night- asthma
• Nauseating and worse after eating- tracheo-oesophageal fistula
 Investigations
1. Sputum-naked eye examination
• Consistently large volumes- bronchiectasis
• Sudden increase in volume- rupture of abscess or
empyema or cyst into a bronchus
• Pink frothy- pulmonary edema/left ventricular failure
• Bloody- malignancy, TB, trauma, pulmonary
embolism
• Yellow/green- infection
• Rusty color- pneumonia
• Black carbon specks- smoking
• Anchovy sauce- ruptured amoebic liver abscess into lung
• Bile-stained- ruptured liver hydatid cyst into right lower lobe bronchus
• Clear- probably saliva
• Clear and colorless- chronic bronchitis
2. Sputum- culture and sensitivity- takes 24-48 hours for bacteria and up to 8
weeks for mycobacteria
• Identify bacteria and test for drug sensitivity
3. Blood Tests- venous blood for automated blood counts (FBC- Full Blood
Count)
• Low Hb- may cause breathlessness
• Raised total white cell count (WBC)- acute bacterial infection
• Normal or low white cell count- mycoplasma or viral infections
• High eosinophil count (eosinophilia)- allergy or parasitic infection
4. Skin Tests- skin-prick testing
• Multiple positive- asthma
• Tuberculin test- tuberculosis
5. Blood gases
• Low arterial partial pressure of carbon dioxide (PaCo2)- hyperventilation
6. Pulmonary Function Tests- by use of a spirometer
• Forced expiratory volume in 1 sec (FEV1)- volume of gas expired in the
first second of expiration
• Peak expiratory flow (PEF)- fastest flow rate recorded during expiration
These are of value in following the course of disease and treatment
7. Imaging
• Chest x-ray (PA- posterior-anterior)- give information about the
nature and location of respiratory disease
• Computerized axial tomography (CT)- for the assessment of
extent of lung cancer and diffuse respiratory disease
Common chest x-ray findings
• Pneumonia- non-homogenous opacity of lobe/area involved
• TB- non- homogenous opacity below the clavicle or in the first
intercostal space and not beyond or apical opacity with or
without a cavity
• Lung abscess- non-homogenous opacity with fluid level seen in
area involved
• Pleural effusion- homogenous lower zone opacity with a cresentric
upper border
• Pneumothorax- hyper-translucent area, devoid of lung markings in the
pleural cavity
• COPD- hyper-translucent lung fields with exaggerated vascular
markings, a flattened diaphragm and a long narrow heart
8. Bronchoscopy- views for mass lesions in the central and mid-zones of
the bronchial tree for carcinoma. Therapeutically for removing
secretions and foreign bodies.
9. Pleural aspirate/biopsy- for both diagnostic and therapeutic reasons.
• Naked eye inspection may suggest pus, blood(cancer or pulmonary
embolism)
• Milky white (chylous=lymph)- a result of obstruction of thoracic duct
Some Physical Signs on Chest Examination
1. Pleural effusion
• Trachea deviated to opposite side
• Reduce chest expansion
• Stony dull percussion note
• Reduced air entry
• Reduced vocal resonance/fremitus
2. Consolidation
• Reduced chest expansion
• Reduced percussion note (dull)
• Increase vocal resonance/fremitus
• Bronchial breathing plus or minus coarse
crackles/crepitations
3. Lung collapse
• Reduced chest expansion
• Reduced percussion note (dull)
• Decrease breath sounds
• Trachea deviated to same side
4. Fibrosis
• Same as 3 above
• Bronchial breath sounds plus or minus crackles
5. Pneumothorax
• Trachea deviated to opposite side
• Decrease chest expansion
• Decrease breath sounds
• Increase percussion note (hyper-resonant)
6. Reduced chest expansion in the following conditions
• Consolidation
• Effusion
• Collapse
• Pneumothorax
• Fibrosis
Continuation with Physical examination findings of our imaginary
Patient, Kofi
(slides 23-26)

At the end of our history taking we made a provisional

diagnosis of right lung disease
We are now going to use the physical examination to
confirm our suspicion
• On inspection kofi was having difficulty in breathing,
using the accessory muscles of respiration and
reduced chest wall movement on the right.
• On palpation trachea was central and chest expansion
was reduced on the right side with increased tactile
vocal fremitus on the right lower chest
• On percussion there was dullness on the right lower chest
• On auscultation bronchial breath sounds were heard over
the right lower lung with increased vocal resonance
The above physical examination findings are signs of
consolidation (slide 88) in the right lower lung, suggestive of
pneumonia on the right.
A plain chest x-ray shows a non-homogenous opacity of the
right lower lobe of the lung (slide 93)
We can now conclude that Kofi has a right lower lobe pneumonia

FINAL DIAGNOSIS: RIGHT LOBAR PNEUMONIA

 2. Cardiovascular System

Introduction (Basics)
The cardiovascular system comprises:
• Heart
• Blood vessels
• Blood
Heart
• The heart has 2 sides- right and left
• It has 4 chambers
- 2 top chambers- right and left atria
The left atrium receives blood from the lungs
The right atrium receives blood from the rest of the body
- 2 bottom chambers right and left ventricles
The right ventricle pumps blood to the lungs
The left ventricle pumps blood to the rest of the body
Blood vessels
• Veins- carry blood from the body back to the heart through
inferior vena cava (IVC) and superior vena cava (SVC)
• Arteries carry blood from the heart to the body through
the aorta
• Capillaries- small (microscopic) blood vessels which
connect arteries and veins together
• Pulmonary artery- take blood to the lungs
• Pulmonary vein- take blood from the lung to the left
atrium
Valves
Are fibrous flaps of tissue found between the heart
chambers and in the blood vessels. They prevent blood
from flowing in the wrong direction
- Valves between the atria and ventricles- are the right
and left atrio-ventricular valves (tricuspid and mitral
valves respectively)
- Valves between the ventricles and the great arteries-
are the semilunar valves (aortic valve at the base of
the aorta, pulmonary valve at the base of the
pulmonary trunk)
- There are many valves found in veins throughout the
body, but no valves found in any of the other arteries
except the aorta and pulmonary trunk.
Presenting symptoms
• Chest pain- angina, MI, pericarditis, dissecting aortic aneurysm,
GERD, pleuritic pain (respiratory), muscle pain
• Cough
• Dyspnoea(breathlessness)- abnormal awareness of one’s
breathing. NYHA classification of breathlessness
I- nil at rest, some on vigorous exercise
II- nil at rest, breathless on moderate exertion
III- mild breathlessness at rest, worse on mild exertion
IV- significant breathlessness at rest and worse even on slight
exertion
- Orthopnoea- breathlessness when lying down
- Paroxymal nocturnal dyspnoea- episodes of breathlessness
occurring at night
• Ankle swelling/edema
• Palpitations- awareness of one’s own heart beat
• Syncope- is a faint
• Claudication- muscle pain that occurs during exercise as a sign
of peripheral ischemia.
• Dizziness
 Additional History Specific to CVS
• Past medical history- angina, MI, ischaemic heart
disease, cardiac surgery
• Family history- first degree relatives with
cardiovascular events
• Drug history- cardiac medications, assess compliance
• Social history- how occupation affected by disease
condition
 Physical Examination

• General Examination
- General inspection- ill looking, short of breath,
overweight/cachectic

- Hands- cold, warm, sweating, finger clubbing, blue nails,

splinter hemorrhages, BP
- Pulses- radial, brachial, carotid, femoral, popliteal, dorsalis
pedis, posterior tibial
- Face- jaundice, pallor
- Mouth- halithosis, blue tongue, moist/dry tongue, pallor
- JVP- raised?
• Inspection of precordium(part of chest overlying the heart)
- Scars of cardiac operations
- Pacemaker implanted
- Visible pulsations
- Abnormal chest shape or movements
• Palpation of Precordium
Place the flat of your right palm over the precordium
- Sustained thrusting pulsation (heave) at the left sternal edge-
right ventricular enlargement
- Palpable murmur(thrill)- severe valvular disease
• Palpate the apex beat (5th left intercostal space ,mid-
clavicular line)
- an abnormal position means enlarged heart.
- No beat felt means:
obesity
pericardial effusion

over inflated emphysematous lung

death or dextrocardia
- Stronger and forceful- anaemia, sepsis
- Tapping- severe mitral stenosis
- Diffuse(poorly localised)- left ventricular aneurysm
- Impulse longer than expected(sustained)- left
ventricular hypertrophy, aortic stenosis
• Percussion
This is to demarcate the heart margin which is not
useful and therefore not included in cardiovascular
examination
• Auscultation
Use the bell of the stethoscope in hairy patient and to detect
low-pitched sounds and the diaphragm for high-pitched
sounds
There are 4 main (standard) auscultation areas
- Mitral(apex)- left 5th intercostal space mid-clavicular line
- Tricuspid- 4th intercostal space at the left sternal edge
- Pulmonary- 2nd intercostal space at the left sternal edge
- Aortic- 2nd intercostal space at the right sternal edge
To locate these standard areas you have to locate the 2nd
intercostal space first
Landmarks to use
- Angle of Louis (joint of manubrium and sternum) is
in line with the 2nd rib, and below it is the 2nd
intercostal space
- Can also use sternal end of the clavicle as landmark-
it lies over the 1st rib and below it is the 1st intercostal
space
In addition to listening to the 4 standard areas also:
- Listen in the left axilla- radiation of mitral
incompetence
- listen over the carotids- radiation of aortic stenosis
 Heart Sounds
Are created from blood flowing through the heart
chambers as the cardiac valves open and close during the
cardiac cycle
• First heart sounds (S1)-closure of mitral & tricuspid valves
- Loud- mitral stenosis, tricuspid stenosis, tachycardia
- Soft- aortic stenosis or regurgitation
• Second heart sounds (S2)- closure of aortic & pulmonary
valves
- loud- hypertension, congenital aortic stenosis
- soft- aortic stenosis, aortic regurgitation
• Third heart sounds (S3)- may occur just after the 2nd
heart sound and described as gallop rhythm eg
mitral regurgitation, VSD
- Normal in children and young adults
- Pathological- aortic and mitral regurgitation,
constrictive pericarditis, dilated cardiomyopathy
• Fourth heart sound (S4)- may occur just before the
first heart sound eg aortic stenosis or HPT heart
disease.
 Heart Murmurs
Unusual sounds heard between heart beats.
Murmurs may be classified into:
1. Innocent Murmurs
May not cause symptoms and can happen when blood flows
more rapidly than normal through the heart such as:
• During exercise
• Pregnancy
• Fever
• Severe anaemia
• Rapid growth in children
• Hyperthyroidism
2. Abnormal (Pathological) Murmurs
May be a sign of serious heart condition such as:
• Congenital heart defect
- Hole in heart
- Stenosis
- Regurgitation
• Heart valve disease
- Valve calcifications- mitral and aortic stenosis
- Infection- endocarditis, rheumatic heart disease
- Valve prolapse- mitral and aortic valve prolapse

Symptoms
If you have a harmless heart murmur you would likely not
have any other signs or symptoms.
An abnormal heart murmur may cause no obvious signs or
symptoms but if you have these signs or symptoms, they may
indicate a heart problem:
• Blue skin (especially finger tips) and lips
• Swelling or sudden weight gain
• Shortness of breath
• Enlarged liver
• Enlarged neck veins
• Chest pain
• Dizziness
• Fainting
• Heavy sweating with minimal or no exertion
In new born
• Difficulty feeding
• Stunted growth
• Breathing difficulties
• Bluish skin during feeding or activity

Examination of Murmurs
1. Systolic Murmurs
Start at or after S1 and end before or at S2
• Systolic ejection murmurs
- benign- fever, hyperthyroidism, severe anemia,
athlete’s heart
- Pathological- aortic and pulmonary stenosis, atrial
septal defects, hypertrophic cardiomyopathy
• Late systolic murmurs
- Mitral and tricuspid valve prolapse
• Pansystolic murmurs- throughout the whole systole
- Mitral and tricuspid regurgitation, VSD
2. Diastolic Murmurs
Start at or after S2 and ends before or at S1
• Early diastolic murmur
- Aortic and pulmonary regurgitation
• Mid diastolic murmur
- Mitral and tricuspid stenosis
• Late diastolic (presystolic) murmur
- Mitral and tricuspid stenosis, complete heart block
3. Other Murmurs
• Continuous murmurs- heard throughout both systole and
diastole- patent ductus arteriosus, arteriovenous fistula
• Radiation- murmurs heard areas the heart sounds are not
normally located. They radiate in the direction of the blood
flow that is causing the sound
- Murmur of aortic stenosis will radiate up to the carotids
- Murmur of mitral regurgitation may be heard in the left axilla
• Position- some murmurs louder with position of patient
- Aortic regurgitation louder if patient sits up, leans forward
- Mitral stenosis louder if patient lies on left hand side
 Other systems involved in CVS examination
The CVS examination is not complete without the examination of:
• Lung bases- crackles- LHF
• Abdomen- hepatosplenomegaly, ascites- RHF, CCF
• Legs- peripheral oedema(CCF), varicose veins

Some Presenting Patterns

• Peripheral vascular disease
- Claudication- muscle pain that occur during exercise
- Shiny, pale, cold limb, hair loss, absent peripheral pulses,
gangrene if severe
• Deep vein thrombosis
- Calf pain, swelling and loss of use
- Warm, tense, swollen limb, erythema, dilated superficial
veins, cyanosis
• The acutely ischaemic limb- rule of Ps
- Painful (at first)
- Painless(numb)
- Pale
- Paralyzed
- pulseless
 Investigations

1. ECG (electrocardiogram)- electrical activity of the heart. The rest ECG is useful in
the diagnosis of myocardial infarction, cardiac hypertrophy, abnormalities of
cardiac rhythm, ventricular hypertrophy and abnormalities of conduction
2. Chest x-ray- it indicates whether the heart and great vessels are enlarged,
calcification or fluid in the pericardium
3. Echocardiography, Doppler flow studies and color-flow Doppler
Analyze reflected high-frequency sound directed at the heart from a transducer on
the chest wall. They permit visualization of the heart valves to determine if they are
stenosed or incompetent
4. Nuclear cardiology- assess function of cardiac muscle
5. Cardiac catheterization and angiography- measuring pressures permitting
evaluation of valvular stenosis and oxygen saturation. Angiography outlines the
inside of the ventricle to assess systolic function and mitral regurgitation
9. Magnetic Resonance Imaging (MRI)-allow diastolic and systolic images to be
produced
 3. Gastrointestinal Tract (GIT)/The Abdomen

Introduction (Basics)
GIT is the tract from the mouth to the anus which include all
the organs of the digestive system (mouth, pharynx,
esophagus, stomach, small and large intestines, rectum and
anus).
There are various accessory organs that assist the GIT by
secreting enzymes and include salivary glands, liver ,
pancreas and gall bladder
The abdomen is the space of the body between the chest
(diaphragm forms upper surface) and the pelvis (pelvic
brim)
 The anterior abdominal wall is artificially divided into 9 parts
for descriptive purposes and differential diagnosis (list of
possible diagnoses). A provisional diagnosis means the
prescriber is not 100% sure of the diagnosis. The site of pain in
any of the 9 parts will give you a clue(differentials) to the cause
of the pain. 4 imaginary lines are drawn
• A horizontal line between the anterior superior iliac spines
• A horizontal line between the lower borders of the ribs
• Two vertical lines at the mid-clavicular point
Surface Anatomy and Differential Diagnosis of abdominal
Pain
 Right upper quadrant pain- cholecystitis, biliary colic,
hepatitis , peptic ulcer, colon cancer, subphrenic abscess
 Epigastric pain- gastritis, peptic ulcer, pancreatitis, aortic
aneurysm
 Left upper quadrant pain- peptic ulcer, colon cancer,
ruptured spleen, subphrenic abscess
 Loin pain- renal colic, pyelonephritis, renal tumour,
perinephric abscess, referred pain from vertebral column
 Left iliac fossa pain- colon cancer, pelvic abscess,
diverticulitis, volvulus, UTI, cancer in undescended
testis, renal colic, hip pathology, in addition to
female(salpingitis, torsion of ovarian cyst)
 Right iliac fossa pain- all causes above including
diverticulitis plus appendicitis
 Central pain- mesenteric ischaemia, abdominal
aneurysm, pancreatitis, worms
 Pelvic pain/supra-pubic pain- UTI, urine retention,
bladder stones, and addition in the female
(menstrual, early pregnancy with problems,
endometriosis, endometritis, salpingitis, torsion of
ovarian cyst)
 Generalized pain- peritonitis, constipation,
gastroenteritis
 Embryologic Origins of Abdominal Pain
- Epigastric pain: foregut(stomach, duodenum, liver,
pancreas, gall bladder)
- Periumbilical pain: midgut(small and large intestines,
appendix)
- Suprapubic pain: hindgut(rectum, urogenital organs)
Presenting symptoms
Abdominal pains, distension, nausea,
vomiting, Diarrhea, constipation, jaundice
Dysphagia(difficulty swallowing)
Odynophagia(pain swallowing)
Rectal bleeding, malena stools
Ascites, weight loss, heart burn
Anemia
 Additional History Specific to GIT
• Past medical history- previous operations
• Drug history- drugs that can precipitate GIT disease
- hepatitis- halothane, antibiotics, methyl dopa
- Acute liver necrosis- paracetamol
- Cholestasis- chlorpromazine, sulphonamides, the pill
- Fatty liver- tetracycline
• Family history- PUD, jaundice, anaemia
• Social history- occupational exposure to hepatotoxins
- Alcohol
- Smoking- risk of PUD, esophageal cancer, colorectal cancer
 Physical Examination

Expose from nipple level up to mid thigh

• General examination
General inspection
- Ill looking, the build, pain, scratch marks, bruising, muscle
wasting
Hand
- Leukonychia (whitish nails), koilonychia, clubbing
- Palmar erythema(thenar, hypothenar eminences)
- Depuytren’s contracture
- Pallor
- Asterixis or hepatic flap (irregular and involuntary jerking
movements)- liver dysfunction, hypercapnia
Face
- jaundice, pallor
Mouth
- breath- fetor hepaticus(sweet smell), uraemia(fishy)
- Angular stomatitis
- Dentition, ulcers
- Glossitis, leukoplakia, candidiasis
Neck
- supraclavicular lymph node on left(Virchow’s node)- suggestive of
gastric malignancy(Troisier’s sign)
Chest
- gynaecomastia
• Inspection
- Is abdomen moving with respiration? If not it is a sign of
peritonitis (inflammation of the peritoneum- covering of
abdominal cavity)
- Is there visible peristalsis?(progressive wave of contraction and
relaxation of a tubular muscle system especially bowel)- bowel
obstruction
- Visible pulsations(aneurysm), dilated veins
- Distension(5Fs- fat, fluid, flatus, faeces, fetus)
- scars, stoma, everted umbilicus
- Masses, herniae
- Striae (stretched marks)- pregnancy, obesity, Cushing’s
syndrome
- Look at the genitalia-present or absent on both sides?
- Look at the hernia orifices for cough impulse-a bulge
when the patient coughs is positive- hernia
- Look for groin swellings
Clinical Significance of the 5Fs
- Fat- obesity
- Fluid- ascites
- Flatus- bowel obstruction or paralytic ileus
- Faeces- constipation
- Fetus- pregnancy, fibroids
• Palpation
Ask patient to indicate areas that may be painful
Whilst palpating be looking at the face to assess
pain
Start away from the site of pain and end there
last. Palpate all 9 areas of the abdomen or the 4
quadrants.
a. Superficial/Light Palpation- This is to elicit tenderness
(pain or discomfort when an affected area is touched),
guarding (tensing of abdominal wall muscles) or
rebound tenderness(Blumberg’s sign)- sensation of
pain felt when pressure is suddenly removed
b. Deep Palpation- to elicit masses (organomegaly)
Palpating the liver (normally not palpable)- start from the
RIF with the patient breathing deeply whilst moving up
2cm at a time until you hit the liver with the radial border
of the index finger
Palpating the Gall bladder (normally not palpable)- felt
as a bulbous, focal rounded mass which moves with
respiration during examination of the liver.
Murphy’s sign- Pain felt over the gallbladder during
deep inspiration- is a sign of cholecystitis. Patient
suddenly stop breathing in the process of breathing in
due to pain caused by the inflamed gallbladder
impinging on the examining finger.
Palpating the Spleen (normally hidden beneath the left
costal cartilages an impalpable)- during palpation your
left hand should be used to support the left of the
ribcage postero-laterally. Start from the RIF (just below
the umbilicus) with your right hand and move towards
the LUQ with each deep breath and feel the movement
of the spleen under your fingers. A palpable spleen may
have a notch infero-medially.
Palpating the kidney- bimanual (both hands) palpation.
For the right kidney,
place your left hand behind the patient at the right loin to move
the kidney up. Place your right hand below the right costal
margin at the lateral border of the rectus abdominis and push
your fingers deep into the abdomen with the patient taking a
deep breath. In this case you will be able to feel an enlarged
kidney between your hands
Repeat the procedure for the left kidney, leaning forward and
placing your left hand behind the patient’s left loin.
This technique of using one hand to move the kidney towards the
other is called renal ballottement.
Differentiating an enlarged spleen and an enlarged left
kidney
Enlarged spleen Enlarged left kidney
- Impossible to feel above it -Possible to feel above it
- Has a central notch medially-No notch
- Dullness to percussion - Resonant percussion note
- Not ballottable - Ballottable
- Enlarge towards umbilicus - Enlarges inferiorly
- Moves inferio-medially on - Moves inferiorly on
inspiration inspiration
Signs for Acute Appendicitis
- Rovsing’s sign- pain elicited in the right lower quadrant
(RLQ) with palpation pressure in the left lower quadrant
- Psoas sign- RLQ pain with extension or flexion of the right
hip against resistance
- Obturator sign- RLQ pain with internal and external
rotation of the flexed right hip
- Dunphy sign- sharp pain in right lower quadrant elicited by
voluntary cough
- DRE (digital rectal examination)- tenderness on the right
side
Scrotal swelling
- If you can go above the swelling it is a mass in the
scrotum eg hydrocele
- If you can not go above the swelling then it is
coming from the abdomen and descending into
the scrotum eg inguinoscrotal hernia.
- To confirm a hydrocele you point a thin beam of
light from a torch. If it transilluminates it means
there is fluid- hydrocele.
Abdominal Hernias (groin hernias)
Examination- the patient should be examined
standing up. With 2 fingers on the mass ask patient to cough and
feel for an expansile cough impulse. If present it is a hernia.
- Direct Inguinal Hernia- herniation/protrusion at the site of the
external ring (an opening at the external oblique aponeurosis
and immediately above and medial to the pubic tubercle)
- Indirect Inguinal Hernia- herniation is through the internal ring
(an opening in the transversalis fascia, halfway between the
anterior superior iliac spine and the pubic symphysis)
With the hernia reduced, press over the site of the internal ring and ask
patient to cough.
An indirect hernia will remain reduced whereas a direct hernia will
protrude once more.
Differentiation of Inguinal Hernias
Indirect Direct
- Can descend to scrotum - Rarely descends to scrotum
- Remains reduced with - Not controlled by pressure
pressure at internal ring on internal ring
- Reappears at internal ring - Reappears in same position
as before reduction
- Causative defect is not - defect in abdominal wall is palpable
palpable
- Femoral Hernias- they are protrusions through the femoral
canal (a small component of the femoral sheath medial to
the femoral vessels)
Examination- patient should be examined standing up and
asked to cough. The femoral hernia will appear as a lump
just lateral and inferior to the pubic tubercle.
Difference between Inguinal and Femoral Hernias
The inguinal hernia is superior and medial to the inguinal
ligament whilst the femoral hernia inferior and lateral to the
inguinal ligament
- Other abdominal Hernias- epigastric, incisional, obturator
• Percussion
Useful for determining:
- Size and nature of enlarged organs (liver, spleen, kidneys,
full bladder)- appear as dullness
- Detecting fluid- fluid thrill, shifting dullness is positive
- Detecting gas (bowel full of gas)- appear abnormally
resonant
Fluid thrill- need an assistant to place hand in the middle of
the abdomen longitudinally whilst flicking on one side of the
abdomen with one hand & the other hand on the other side
receiving the impulse
Shifting Dullness
- With patient supine percuss abdomen centrally to
laterally until dullness is detected (this marks the
fluid level)
- Keep your finger pressed there and ask patient to roll
onto the opposite site
- Ask patient to hold new position for ½ a minute and
repeat percussion moving laterally to central
- The previous dull area will be resonant (where finger
was pressed on) confirming fluid in the abdomen.
• Auscultation
For bowel sounds. Press the diaphragm of the
stethoscope deep, just below the umbilicus for 2
minutes
- Normal- low-pitched gurgling, intermittent
- Absent- after 2 minutes listening- ileus or peritonitis
- Increased and tinkling- obstruction
- High-pitched(tinkling)- bowel obstruction
- Borborygmus- loud low-pitched gurgling that can be
heard without a stethoscope- diarrhoea, abnormal
peristalsis
- Listen for bruits(like heart murmurs)- aneurysms where
suspected- above umbilicus (aorta aneurysm), either
side of umbilicus (renal aneurysm), epigastrium
(mesenteric stenosis)
- Listen for Succussion splash- is a splashing sound heard
through a stethoscope during sudden movement of the
patient on abdominal auscultation- gastric outlet
obstruction
 Digital Rectal Examination (DRE)
• Ask patient to lie on left lateral position with legs
bent and knees drawn up
• With pairs of gloves separate the buttocks and
inspect the perianal area for skin tags, warts, fistula,
abscess
• Ask patient to strain and watch for haemorrhoids,
rectal prolapse
• Lubricate the tip of your right index finger with jelly
• Place the pulp of your finger against the anus and
press firmly to allow the sphincters to relax then
gently advance the finger into the anal canal
• Assess the sphincter tone
• Rotate the finger around to feel for any thickening
and irregularities and points of tenderness
• In the male identify the normal prostate which is
smooth, firm and rubbery
• Gently withdraw your finger and inspect the glove for
blood, mucus, colour of stool
Look for Signs of Peritonitis
- Abdomen does not move with respiration
- Pain on light palpation
- Rebound tenderness
- Involuntary guarding
- Absent bowel sounds
 Investigations
1. Stool naked eye examination
• Colour
- Black- ingestion of iron or bismuth, bleeding
occurring high up the intestine
- Pale- lack of entrance of bile into the intestine as in
obstructive jaundice, rapid passage of stool through
intestine as in diarrhoea, high fat content as in
malabsorption
• Odour
- offensive- jaundice
- Free of odour- cholera
- Smells like semen- amoebic dysentery
• Form/Consistency
- Dry and harder than normal- constipation
- More fluid than normal- dirrhoea
- Rice water- cholera
- Purulent/pus containing stool- severe dysentery,
ulcerative colitis
- shiny/mucoid stools- affection of large bowel
• Bloody
- Red currant jelly- intussusception
- Less intimately mixed with fecal matter- bleeding from
large intestine
- Merely streak the fecal matter/drops on it- rectal or anal
bleeding- hemorrhoids
- Fecal material mixed with blood and pus- bacillary
dysentery
- Fluid fecal material, mucus and small amounts of blood-
amoebic dysentery
2. Endoscopy- direct vision and biopsy of lesions as well as therapeutic
interventions
• Upper gastrointestinal endoscopy- esophagitis, gastric ulcers and
tumors, duodenal ulcers are readily seen and biopsied and bleeding
can be arrested
• Sigmoidoscopy and colonoscopy- used to examine distal and entire
colon
3. Radiology
• Barium meal/enema- endoscopy has reduced the need
• Plain abdominal x-ray- to confirm clinical suspicions of intestinal
obstruction
4. Ultrasound and CT scanning- especially useful in the investigation of
liver, pancreas and biliary tract
5. Histopathology- biopsy- for confirmation and staging
of tumours
6. Blood Tests- provide evidence of malabsorption
(macrocytic/hypochromic microcytic anemia),
malnutrition (low transferrin and lymphocyte count)
and liver function tests
7. Fecal occult blood- intestinal blood loss
8. Microbiological stool examination- for parasites
9. Laparoscopy – direct vision of the abdominal cavity
for intra-abdominal disease
 4. Integumentary System(Skin, Hair and Nails)

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

• Hair loss
• Abnormal hair growth
• Nail changes
• Skin color/pigmentation
• Skin lesions/eruptions
• Lump
• ulcer
 Additional History Specific to Skin
• Past medical history- previous skin problem, DM, what patient use
on skin (soaps, creams)
• Drug history- drugs taking and duration, topical and over the
counter drugs, allergies and nature
• Family history- atopy, eczema, skin cancers
• Social history
- Exposure to STIs
- Insect bites
- Living conditions- crowding
- Hobbies- pets
- Occupation
 Examination of a Skin Lesion

Scan the whole surface of skin for any abnormal lesions.

Remember to inspect those areas that are usually hidden
(inner thighs, undersurface of breasts, axillae, natal cleft,
external genitalia). If any lesion found then inspect
thoroughly noting the following:
• Number, location and distribution
- Distal areas (hands and feet)- hand, foot and mouth
disease
- Extensor areas (elbows and knees)- psoriasis
- Flexural distribution (axilla, genital organs, cubital fossae)-
eczema
- Follicular distribution (areas of increased number of sebaceous
glands- face, chest)- acne
- Dermatomal distribution (confined to one/several dermatomes
and do not cross midline)- herpes zoster
- Seborrhoeic distribution (areas where there is increased
sebaceous glands- scalp)-seborrhoeic dermatitis
• Size of lesion(s)
Measure width and height(if raised)
Note configuration of lesions (shape or outline)
- Descrete (individual or separate from one another)- mole
- Confluent lesions (merging together)- urticarial
- Linear lesions (line shape)- excoriations
- Discoid lesions (coin-shaped)- discoid eczema
- Target lesions (concentric rings of varying color)- erythema
multiforme
- Annular lesions (ring-like)- tinea corporis
• Color of lesions
- Redness of skin- erythematous lesion
- Reddish/purple discoloration of skin-purpura (<2mm diameter),
petechiae (>2mm diameter), ecchymoses
- Darker skin- diffuse (Addison’s disease), descrete (linea nigra in
pregnancy)
- Paler skin- pityriasis versicolor
- Areas of skin appear completely white- vitiligo
• Morphology
A. Primary lesions- develop as a direct result of a disease process
Flat, non-palpable changes in skin color
- Macule- flat non-palpable change in skin colour <0.5cm diameter
- Patch- flat non-palpable change in skin colour > 0.5cm diameter
Elevation due to fluid in a cavity
- Vesicle- fluid below the epidermis <0.5cm diameter
- Blister- fluid below the epidermis >0.5cm diameter
- Bulla- large, fluid-filled lesion below the epidermis >10cm
diameter
- Pustule- visible collection of pus in the subcutis
- Boil/furuncle- staphylococcal infection around/within hair
follicle
- Carbuncle- multiple boils/furuncles of adjacent hair follicles
Elevation due to solid mass
- Papule- a raised area <0.5cm diameter
- Nodule- a mass/lump >0.5cm diameter
- Callus- hyperplastic epidermis- found on soles, palms and
areas of excessive friction
- Plaque- a raised area>2cm diameter
- Wheal- dermal oedema
Loss of skin
- Erosion- partial epidermal loss
- Fissure- a linear crack
- Ulcer- full thickness skin loss
- Atrophy- thinning of the epidermis
B. Secondary lesions- are modifications of primary lesions due to
trauma, or evolution of the primary lesion
- Lichenified- thickening of epidermis with exaggerated skin markings
- Excoriation- scratch marks (loss of epidermis)
- Crust(scab)- dried exudate
- Scale- small horny epithelium resembling fish skin
- Ulcer- localized defect in the skin
- Fissure- sharply-defined linear or wedge-shaped tear in
the epidermis
- Striae (stretch marks)- purple lines on the skin due to
rapid growth or overstretching of skin- ascites, Cushing’s
syndrome, growth spurts
- Scar- new fibrous tissue which occur after skin injury-
atrophic scar (thinning of normal tissues underlying the
scar), hypertrophic scar (hyper-proliferation of scar tissue
within wound boundary), keloid (hyper-proliferation of
scar tissue beyond wound boundary)
C. Vascular lesions
- Telangiectasia- early visible superficial blood vessel
- Spider naevus- single telangiectatic arteriole
- Purpura- rash caused by blood in the skin, often multiple
petechiae
D. Hair loss(alopecia)
- Alopecia areata- sharply defined , non-inflammatory bald
patches on the scalp.
- Alopecia totalis- loss of hair from all of the scalp
- Alopecia universalis- loss of all body hair
- Scarring alopecia- inflammatory lesions causing hair loss
E. Abnormal hair growth-hirsuitism in females
F. Nail changes
- Splinter haemorrhages- tiny longitudinal streak
haemorrhages under nails caused by micro-emboli, trauma
- Pitting- tiny indentations in the surface of the nails caused
by psoriasis
- Onycholysis- premature lifting of the nail
- Leukonychia- white coloration of the nail caused by low
albumin or chronic ill health
- Beau’s lines- transverse depressions in the nail- sign of
arrested nail growth in acute illness
- Paronychia- infection of skin adjacent to nail
- Koilonychia- spooned shaped nail(concave indentation)
- Clubbing- increased curvature of nail
- Onychomycosis- thickened, opaque and yellow nail due
to fungal infection
• Skin colour/pigmentation
- Pallor- anaemia, shock, intense emotion
- Redness- overheating, extreme exertion, some fevers
- Cyanosis- bluish skin- impaired oxygenation
- Jaundice- yellow tinge of skin and sclera
- Carotenaemia- yellow/orange tinge of skin but sclera
is spared
- Albinism- congenital absence of pigment which is
generalized
- Vitiligo- alternating patches of white and dark
pigmented skin
- Haemorrhages- bleeding into the skin
 Examination of a Lump

Note the following:

• Site- anatomical location
• Size- measured and stated in 2 or 3 dimensions eg I palpated a
3x4x5cm mass
• Shape- spherical, oval, round etc
• Surface
- Appearance- smooth, rough, flat/raised, regular/irregular
- Color- red or inflamed, pigmented
• Consistency
- hard- possibly cancer
- Fluid-filled- tense/hard, rubbery, spongy
- Soft- more likely lipoma
• Fluctuation- put fingers on either side of the lump opposite
each other. Press with one finger and feel whether the lump
bounces against your other finger-fluid-filled or fat-filled
• Trans-illumination- shine a pen torch light across the lump in
a dark room. Clear fluid will glow- simple cyst, cystic
hygroma, hydrocele, lipoma
• Pulsatility- suggesting vascular origin
- Pulsation from lump itself- pulsatile and expansile- aneurysm
- Transmitted from nearby vessel- pulsatile and not expansile
(just upwards)
• Compressibility- emptied by pressure but reappear
spontaneously on release of pressure- varicose veins,
saphina varix
• Reducibility- disappear with pressure and do not
return spontaneously- inguinal hernia
• Mobility- with respiration or with muscular
contraction
• Auscultation
- Bruits- vascular lesions, enlarged thyroid
- Bowel sounds- over an inguinal hernia
• Depth (which layer is the lump in)
- Does it move with the skin? Then epidermal, dermal-
ganglion, sebaceous cyst
- Does the skin move over it? Then subcutaneous-
lipoma
- Does it move with contraction? Then in
muscle/tendon
- Does it move only in one direction? Then in
tendon /nerve. If nerve then patient might feel pins-
and-needles if compressed
 Examination of an Ulcer

Use the pneumonic BBEDDS for inspection

• Basics- site, size, shape (margin-regular, irregular)
• Base- healthy, granulation tissue, slough, bone, tendon
• Edge- PURSE
- Punched out- trophic, arterial ulcer
- Undermined- pressure, tuberculosis
- Rolled- basal cell carcinoma
- Sloping- venous
- Everted- squamous cell carcinoma
• Depth- the layer of skin it extends to (measure height)
• Discharge- pus, blood, serous fluid
• Surroundings- skin changes, color, scars
Malignant Melanoma
There are 2 systems to assist diagnosis
• American (ABCD)
Asymmetry
Irregular Border
Irregular Color
Diameter> 1cm
• British Glasgow 7-point checklist
Major features
- Change in size
- Change in shape
- Change in color
Minor features
- diameter> 5mm
- Inflammation
- Oozing or bleeding
- Itch or altered sensation
Any lesion with 1 major feature should be considered
for removal
Additional minor features add to the clinical suspicion
of melanoma
 Investigations

• Skin biopsy- size and depth of biopsy depend on the nature of the
lesion
• Microbiological
- Swab from exudate or pus for microscopy or culture & sensitivity
- Aspiration of blister fluid for microscopy or culture
- Skin scrapings, nail clippings for examination under Wood’s light
or direct microscopy
- Blood samples for culture
• Patch testing- reproduces a delayed hypersensitivity reaction to
suspect allergens applied to the skin surface
• Prick test- with allergen extracts and result in immediate (type I)
skin reaction
 Techniques of Physical Examination

1. GENERAL EXAMINATION
• Stand at the foot end of the bed on the right side of the
patient lying with head raised with pillow and feet exposed.
• State how sick patient is eg very ill looking
• Pattern of breathing- eg cheyne-stokes breathing
• Shape/build- obese
• Orientation in place, time and person- ask questions like:
where are you now?(place), whom am I? (person),what part
of the day are we now? (time).
• Check for varicose veins
• Palpate for pitting edema
 Move up a bit and hold the patient’s hand
• Check hydration status- pinch back of hand
• Check radial pulse if not already done as part of the
vitals (BP, pulse, respiration)
• Check for palmar pallor
• Check for peripheral cyanosis
• Check for choilonychia
• Check for clubbing of fingers
 Move to the head
• Check for halithosis
• Check position of ears, nose, hair distribution
• Check for jaundice
• Check for central cyanosis- from tongue
• Check for dehydration- from tongue
• Check for pallor- from tongue
 2. Physical Examination of Respiratory System

Expose whole chest with patient sitting

Inspection
• Use of accessory muscles of respiration?
• Respiratory rate- if not already done as part of vitals
• Breathing pattern
• Chest wall movements
• Chest wall deformities
• Examine sputum if available
 Palpation
• Check fingers for clubbing, peripheral cyanosis, tar
staining- if not already done
• Check cervical nodes – standing behind the patient
• Check trachea deviation- standing in-front of patient
Then let patient lie down
• Measure chest expansion
• Tactile vocal fremitus
 Percussion
• Compare both sides of the chest inch by inch
• Anterior chest wall
• Posterior chest wall
• Lateral chest walls
Auscultation
• Vocal resonance
• Breath sounds- normal, diminished, absent, bronchial
• Added sounds-rhonchi, crepitations/crackles, pleural
rub
 3. Physical Examination of the Cardiovascular System

Expose whole chest with patient lying at 45 degrees

Inspection
• Is patient short of breath at rest?
• Is there any cyanosis?
• Look for the JVP. Is it elevated?
• Look at the precordium (part of chest overlying the heart)
- Any scars of heart operations?
- Abnormal chest shape or movements
- Any visible pulsations?
• Look for ascites
• Any pedal edema?
• Any varicose veins?
Palpation
• Radial/brachial pulse and BP if not already done
• Measure JVP if elevated
• Palpate precordium for heave (sustained thrusting
pulsation), thrill (palpable murmur)
• Palpate for the apex beat (left 5th intercostal space,
mid-clavicular line)
• Look for hepatomegaly
• Elicit pitting edema if pedal swelling
Percussion- not done
Auscultation
• The carotid artery for bruits
• Locate the 4 auscultation areas (mitral, tricuspid,
pulmonary, aortic)
• Auscultate for heart sounds, murmurs and radiation of
murmurs (to the carotid- aortic stenosis, to the axilla- mitral
regurgitation) if present
• Auscultate base of the lungs for crackles
 4. Physical Examination of the Abdomen(including
Urogenital System)

Expose from nipple line to mid thigh whilst covering the

genitalia
Inspection
• Movement with respiration?
• Umbilicus- inverted, everted?
• Distended veins
• Visible peristalsis, pulsations
• Shape-scaphoid, distended, obese?
• Scars, stomata
• Masses
• Look at hernia orifices
• Groin swellings
• Genitalia
Palpation – auscultation may be done before palpation
depending on the situation
• Do both superficial and deep palpation whilst watch
the face for any sign of pain
• Superficial palpation- for tenderness
• Deep palpation- for masses
• Murphy’s sign- gall bladder
• Rovsing’s sign- appendix
• Bimanual palpation- kidney
• Elicit loin tenderness- for pyelonephritis
Percussion
• For gas, solid organ
• For fluid- fluid thrill, shifting dullness
Auscultation
• Bowel sounds- absent, present, increased