Examining the Cardiovascular System

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Second Edition 2013

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NOTE: This is the second edition of this booklet. Spelling mistakes have been corrected, some
figures and definitions have been added for a better understanding.. (:

General Structure of history taking and general examination

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History and Examination of the Cardiovascular System

15
History and Examination of the Respiratory System

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History and Examination of the Gastrointestinal System

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History and Examination of the Nervous System

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History and Examination of the Genitourinary System

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History and Examination of the Rheumatological System

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History and Examination of the Endocrine System

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History and Examination of the Hematological System

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How to Report your Examination?

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Frequently Asked Questions& Cranial Nerves

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References
151

Contents
Confidence comes from the
continual repetition of
certain activities..
Listen, see, be involved &
try yourself..
Prepare for a new
Challenge..

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General Structure of History Taking, and General
Examination:

History Taking:
1. Personal data
2. Chief complaint
3. History of the presenting illness
4. Past history
5. Medication history
6. Blood transfusion
7. Allergies
8. Menstrual history
9. Family history
10. Social history
11. Systemic review
12. Summary

General Examination:
1. General appearance
2. Vital signs
3. The hand
4. The head
5. The neck
6. Lymph nodes
7. Lower limbs
8. The back

Important Analysis

Do Not Fear
Mistakes

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History taking:

Important Points to Put in Your Mind:

Say:
Introduce yourself to the patient as a student doctor.
Take the permission.
Close the curtain.
Sit down
In order to obtain a good history, the clinician must:

- Establish a good relationship.
- Interview in a logical manner.
- Listen carefully.
- Allow the patient to tell the whole story then ask questions to fill in the gaps.
- Interrupt appropriately.
- Note non verbal clues.
- Correctly Interpret the information obtained.
- Show an interest.
- If the patient stops giving the story, it can be useful to provide a short summary of what
has already been said and encourage the patient to continue.
- Avoid using medical terms.

1. personal data:
Name.
Age.
Nationality.
Gender.
Residency.
Marital status.
Children
Occupation

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2. Chief complaint (CC):
Time of admission (admitted when?): mention the date.
Route of admission: through ER electively through OPC, or by referral.
Complaining of (no medical terms &in a chronological order).
If the CC is pain, mention the site.
The duration (for how long?) of each symptom alone.

Chronic illness (es), e.g., the patient is known to be.. since. on (medications) .., and
mention if there are any complications.
Analysis of the CC(s) in a chronological order:
- Onset and offset.
- Duration.
- Course.
- Character.
- Severity.
- Aggravating and relieving factors.
- Associated symptoms.
Systemic review of the systems involved in the CC(s).
Previous episodes: if yes:
- How many times?
- When was the first and last episode?
- Same or more severe episodes (progression).
- How did it relieve?
- Did the patient go to a doctor?
- The diagnosis?
- What was done (medications, investigation, or hospital admission)?
Constitutional symptoms: fever, loss of appetite, and weight loss.
Risk factors.
hospital course: (what was done to the patient during this admission: investigations,
medications, procedures and their results)
Functional history: (how the disease affects the patient's life daily activity) e.g: going to
the school or work.
Analysis of the chronic illnesses that related to the CC(s):
- It was diagnosed on (where and when?) by type of investigation?
- Monitoring (yes or no, if yes how?).
- Regular follow up in a health care center.
- Medications. Always taken or missed.
- Complications and their duration.

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3. Past History:

Past Medical:
- Chronic illnesses not related to the CC(s).
- Childhood problems.
- Any other disease, e.g infection, inflammation, tumor, and for each disease.
a. When was diagnosed? By which type of investigations?
b. Controlled or not.
c. Drug compliance.
d. Complications, and their duration.
Past surgical or interventional procedures: What? Why? When? Complications?
Hospital admissions: When? Why? What was done? ICU admission?
Past accidents and their consequences, e.g. fractures, trauma.
History of physiotherapy or rehabilitation.

4. Medication history:

Drug For (the disease) route dose frequency duration

Any complication (adverse effects) of the medications.
Use of herbal medications (especially in liver diseases, or jaundice).

5. Blood transfusion:
When Why? How many units? Complications?

6. Allergies:
Against what, egg, food, drugs, contrast.
What is the kind of the allergic reaction (symptoms)?
How does it relief?
- If negative, say: "No known allergy (NKA)"

7. Family history:
Family members and their health.
Causes of death.
Similar illness (or presentation) in the family: duration, their ages when the disease
presents.
Any inherited disease: diabetes, hypertension, cancer, or any inherited disease that is
illness related.
Congenital abnormalities or diseases.

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8. Menstrual history:
Age of menarche.
Age of menopause.
LMP (last menstrual period).
Regularity (note if there is dysmenorrhea or amenorrhea).
Duration.
Amount.
Pregnancies (number, any problem with pregnancy?).
Deliveries (number, normal/c-section).
Abortions (number, cause).
OCP (oral contraceptive pills) and HRT (hormonal replacement therapy): if yes, for how
long and which type.
Any gynecological problems, e.g: bleeding, tumor.

9. Social history:
Place of birth, and residency.
Marital status and number of children.
Who is taking care of the patient (to assess if he/she can do his/her daily activity or
needs help).
Level of education.
Socioeconomic status.
Occupation.
Habits: smoking, drinking alcohol, drug abuse.
Any activities or exercise.
History of traveling to an endemic area (where?) or contact with infectious people
(when?).
History of close contact with animal.
Immunization.

10. Systemic review:
CVS, Respiratory, GIT, GUT, CNS, Endocrine, Rheumatological, Hematological, Skin.

11. Summary:
Age.
Gender.
Chronic illnesses.
CC(s) and the duration.
Important negatives.
The patient was admitted for further evaluation and management.

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Examination:

1. Pre-exam Checklist : WIPE

Wash your hands.
Introduce yourself to the patient.
Positioning of the patient and his/her Privacy.
Exposure.

** Remember:

Always examine from the right side of the patient (and tell the examiner if you are left
handed).
Ask the patient if there is any tenderness before touching him/her.

2. General appearance (ABCDE):
Appearance: young, middle aged, or old, and looks generally ill or well.
Body built: normal, thin, or obese.
Connections: such as nasal cannula (mention the medications), nasogastric tube, oxygen
mask, canals or nebulizer, Holter monitor, I.V. line or cannula (mention the medications).
Color: jaundiced, pale, or cyanosed.
Distress: in pain, respiratory (using accessory muscles), or neurological (abnormal movements)
distress.
Else: mental functions: consciousness, alertness, and orientation.

3. Vital signs:
Pulse rate:
- Rate: counting over 30 seconds, normally 60-100.
- Rhythm: regular or irregular.
- Synchronization by comparing with the other side (radioradial or radiofemoral delay).
- Character and volume: determined from the carotid.
Blood pressure (BP) : Normal BP defined as a systolic reading less than 140, and diastolic
reading less than 90.
Temperature: Normal body temperature ranges from 36.6-37.2 C.
Respiratory rate:
- It is traditional to count it while taking the pulse.
- The normal rate at rest should not exceed 25 beat per minute (range 16-25).

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4. The hand:
Dorsum:
- Muscle wasting.
- Pigmentations.
- Skin lesion (including scars).
- Tendon xanthomata*: hyperlipidemia.

Palm:
- Signs of infective endocarditis such as Osler's nodes* and Janeway lesions*
- Palmar xanthomata: hyperlipidemia.
- Sings of a respiratory disease, or nicotine staining.
- Palmar erythema (redness of the palms of the hands): liver cirrhosis, polycythemia,
pregnancy.
- Pigmentation of palmar creases: Addison's disease but may be normal in Asians and
black.
- Pallor of palmar creases: anemia (becomes clearer with hyperextend fingers).
- Dupuytren's contracture*: alcoholism.
- Raynaud's phenomenon*

Nail
- Clubbing.*
- Signs of infective endocarditis like splinter hemorrhage.
- Leukonychia*: hypoalbuminemia, liver disease, or nephritic syndrome.
- Koilonychias*: iron deficiency anemia.

Flapping tremor*
- CO
2
retention.
- Hepatic encephalopathy.
- Renal failure.

* See next page

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Splinter hemorrhage: linear bleeding
under a fingernail or toenail, resembling
a splinter.

A small, tender,
nodular cutaneous
lesion in the pads
of fingers or toes.
A small erythematous
or hemorrhagic lesion,
usually on the palms
or soles.

Clubbing: A condition affecting the fingers and
toes in which the extremities are broadened
and the nails are shiny and abnormally curved.

- Dupuytren's contracture: A disease of the palmar fascia resulting in thickening and contraction of
fibrous bands on the palmar surface.

- Raynaud's phenomenon: abnormal response of fingers and toes to cold. First turn white (ischemia),
then blue (cyanosis) and finally red (revascularization, it is the most severe and painful-stage ).

- Leukonychia: abnormal whiteness of the nails either total or in spots.

- Koilonychias: dystrophy of the fingernails in which they are thinned and concave with raised edges.

- Flapping tremor: Involuntary jerking movements of the hands due to accumulation of toxins. The
tremor is usually induced by extending the arm and dorsiflexing the wrist.

- Tendon xanthomata: nodules found in the tendons of the hands, feet, and Achilles.

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5. The head:
Scalp: hair deficiency or excess.
Eye:
- Jaundice (in the sclera): liver disease, hemolytic anemia.
- Pallor (in the conjunctiva): anemia.
- Xanthelasma (patches of yellow skin around the lower or upper eyelids): hyperlipidemia,
primary biliary cirrhosis.
NOTE: Jaundice is better to be seen in the daylight.

Mouth:
- Central cyanosis (blue discoloration seen in the tongue due to increase in the
deoxygenated heamoglubin)
- Oral hygiene.
- Dryness of the mouth: dehydration.
- Any lesion, e.g: ulcer, bleeding.

special smell:
- Sweet smell "fetor hepaticus'': liver disease.
- Ammoniacal fish breathe" uremic fetor": renal failure.
- Cigarette smell in smokers.

6. The neck:
Lymph nodes.
Salivary glands.
Thyroid.
lf there is any swelling, describe it (site, size, shape, skin and surrounding tissue,
consistency)
7. Lymph nodes: (see hematology examination)
- Epitrochlear - Axillary - Cervical - Supraclavicular - Inguinal

8. The lower limb:
Any change in the nails, dorsal, or the sole of the foot.
Peripheral pulses: popliteal, posterior tibial, and dorsalis pedis pulses.
Lower limb edema.

9. The back: Sacral edema.

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Important Analyses:

1. Pain:
Onset.
Duration.
Site.
Radiation.
Character.
Severity.
Continuous or intermittent.
Frequency, and the duration of each episode.
Progressive or constant.
Daily pattern.
Precipitating, aggravating and relieving factors.
Associated symptoms: symptoms of differential diagnosis.

2. Weight loss:
Appetite: normal, decreased, or increased.
How many kilograms? Over what time span has the weight been lost? What does the
patient thinks the cause, e.g: thyrotoxicosis, malignancy... etc.
More than 10% loss in 6 months is significant (make sure that the patient is not on diet).

3. Fever:
Onset.
Duration.
Continues, remittent, or intermittently.
Diurnal pattern.
Changes in severity.
Progression over time.
Measured or not if yes: route and readings.
Associated symptoms:
- Chill: sensation of cold.
- Rigors: uncontrolled shivering occurs when a patient's temperature rises rapidly.
Management: what was done to lower it?

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4. Diabetes and Hypertension:

When was diagnosed? By which type of investigations?
monitoring if yes, how?
Regular follow up in a health care center.
Medications, always taken or missed.
Risk factor.
Complications, and their duration.

Diabetes Hypertension
Presentation Polyuria, polydipsia, weight loss, lethargy. Visual impairment, nausea, vomiting, fits,
headache, symptoms of acute cardiac failure.
Risk factor - Family history.
- Obesity.
- Pancreatic disease, Endocrine disease:
Cushing's, acromegaly.
- Drugs: corticosteroids, thiazide
diuretics.
- Family history.
- Obesity.
- High alcohol intake and high salt intake.
- Renal disease.
- Endocrine disease: Cushing`s, acromegaly,
Conn`s, pheochromocytoma.
- Drugs: oral contraceptive, steroids,
vasopressin.
- Coarctation of the aorta
- pre-eclampsia (3rd trimester of pregnancy).
complication - Vascular disease.
- Eye disease (ask about previous laser
procedure).
- Neuropathy (ask about numbness).
- Nephropathy (ask about frothy urine).

- Cerebrovascular disease (stroke).
- Coronary artery disease.
- Renal failure.
- Peripheral vascular disease.

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5. Smoking:
Cigarette, cigar or pipes.
How many per day? How many years?
Complications:
- Cardiovascular disease.
- Chronic lung disease, e.g: COPD.
- Peptic ulcer.
- Cancers.
- Fetus damage or abnormality (if the patient is female).
If the patient stopped smoking, when and why?

6. Alcohol drinking:
Which type? How much? How often?
Complications:
- GIT: erosion, bleeding, pancreatitis, liver disease, cancer.
- CVS: arrhythmia, hypertension, cardiomyopathy.
- CNS: blackout, peripheral neuropathy, cerebellar disease, dementia.

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History and Examination of the Cardiac System:

Major Symptoms:

1. Chest pain.
2. Dyspnea.
3. Ankle swelling.
4. Palpitation.
5. Syncope.
6. Intermittent claudication.
7. Fatigue.

Other items in the History.

Cardiovascular Examination:

1. Pericardium Examination.
2. Peripheral Examination.

Have Pride in
Yourself..

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Major Symptoms :

1. Chest pain or heaviness:
Duration.
Location.
Mode of onset: sudden or gradual.
Pattern: Constant or Progressive.
Radiation.
Character.
Course: continues or intermittent
Severity.
Precipitating, aggravating, and relieving factor.
Associated symptoms.

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2. Dyspnea (Cardiac dyspnea):
Exertional, the severity is assessed by New York Heart Association Classification (NYHA):
- Class I: only on heavy exertion.
- Class II: on moderate exertion (more than usual activity).
- Class III: on minimal exertion (at usual activity).
- Class IV: at rest.
Orthopnea: Dyspnea on lying down Severity reflected by the number of pillows been used.
Paroxysmal nocturnal dyspnea (PND): Severe dyspnea that wakes up the patient from sleep
gasping for air.

3. Ankle swelling (edema):
Symmetrical.
Unilateral or bilateral.
The level: to the ankle, below the knee, the middle of the thigh, the abdomen, or the sacrum
in bed ridding patients.
The progression:
- From foot upward: heart failure.
- Ascites then lower limb edema: constrictive pericarditis.
- Worsens at evening, and improves during the night.

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4. Palpitation:
Unexpected awareness of the heartbeat.
The mode of onset and termination.
Specific triggers: exercise, alcohol, caffeine.
Frequency.
Duration of attacks.
Rhythm (ask patient to tap out): regular or irregular.
Fast or slow.
Syncopal attack or any associated symptoms.
Age of onset.
5. Syncope, presyncopal attack, and dizziness:
Syncope: transient loss of consciousness resulting from cerebral anoxia.
Presyncopal attack: transient sensation of weakness without loss of consciousness.
Dizziness: the world seems to be turning around
When and why?
Frequency.
Symptoms preceding the attack (i.e. an aura) : palpitation, chest pain, or dizziness).
The duration of the attack.
Any known diagnosis.
6. Intermittent claudication: Pain in one or both calves, thighs or buttocks during walking more
than a certain distance (the claudication distance).

Description of the pain.
Comes with walking, exercise, or at rest.
The distant needed to cause pain.
The time needed to recover.
Reappearance after walking the same distant.
Can the patient walk through the pain or not.
How long have you had the problem? Progression: worsens or no change.
Affecting lifestyle.
What relieves the pain?
7. Fatigue:
Commonly with heart failure or diseases that lead to fatigue and cardiac symptoms like
anemia, i.e. causes palpation and fatigue.

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Other Items in the History:

1. Personal data: age and sex:
- Male above 50: coronary artery disease (CAD).
- Female above 30: rheumatic heart disease (RHD).

2. History of the presenting illness: Risk factors:
Ischemic heart disease (IHD):
- Type II diabetes mellitus (DM).
- Hypertension (HTN).
- Hyperlipidemia.
- Smoking.
- Obesity and inactivity.
- Family history.
- Male sex and advanced age.
- Raised homocysteine level ( is a naturally occurring amino acid found in blood plasma).
- Type A personality.

Heart Failure:
- Risk factor of IHD.
- Congenital heart disease.
- Valvular heart disease.
- Thyrotoxicosis.

Valvular heart diseases:
- Rheumatic fever.
- Congenital valvular disease.
- IHD.
- Heart failure.
- Connective tissue disease.
- Myocardial infarction (MI).
- Drug abuse (infective endocarditis).

Arrhythmia:
- Risk factor of IHD.
- Excessive use of alcohol.
- Drug abuse.
- Stress.
- Certain over-the-counter (without a prescription )and prescribed medications.
- Dietary supplements and herbal remedies.

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3. Past history:
Past medical:
- MI.
- IHD.
- RHD.
- Resent dental work.
- Transient ischemic attack (TIA).
- Stroke: Loss of vision, Dysarthria, Monoplegia.
- Thyroid disease.
Surgical (interventional) history:
- Open heart surgery or any cardiac or valvular surgery, e.g. CABG (coronary artery bypass
grafting).

4. Family history:
Premature CHD in a first-degree relative: a male aged less than 55, or a female aged less
than 65.
HTN, DM, or hyperlipidemia.
Familial hypercholesterolemia.
Systemic lupus erythematosus (SLE).

5. Social history:
Smoking.
Alcohol.
Caffeine consumption.
Drug abuse.

6. Medication history.

7. Blood transfusion.

8. Allergies.

9. Menstrual history.

10. Systemic review.

11. Summary.

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Cardiovascular Examination:

- Position: sitting.
- Exposure: full exposure of the trunk (if you could not, tell the examiner from the beginning).

1. General appearance and vital signs:
Radial pulse:
- Character*: anacrotic, plateau, bisferiens, collapsing, alternans.

- Desynchronization: coarctation of the aorta ( a congenital narrowing of the arch of the aorta).

- Water-hammer test: detects the collapsing pulse, which is pathognomonic for aortic
regurgitation. (To detect this, the radial pulse of a supine patient with arm at side is firmly palpated
with slight pressure until the pulse is obscured. The arm is then raised over the patient's head, with the
arm perpendicular to the supine patient).

Blood pressure: Pulsus paradoxes: a change in the systolic pressure during inspiration more
than 10mmHg.

2. Precordium examination:

Inspection:

a. Shape and deformities:
- Pectusexcavatum (funnel shaped; depressed sternum: Marfan's syndrome*).
- Pectuscarinatum (pigeon shaped; prominent sternum).

b. Scars: median sternotomy.
c. Devices:
- Holter monitor: an ambulatory 24 hours ECG.
- Pacemaker, or intracardiac defibrillator (lCD): usually below the left or right clavicle.
d. Apex beat: with the aid of torch.

* See next page

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Palpation:

a. Apex beat: The most inferolateral palpable pulse.
- If it is impalpable, ask the patient to turn to the left.
- The beat may be:
Normal.
Tapping: mitral stenosis (MS), tricuspid stenosis (TS).
Double impulse: hypertrophy cardiomyopathy.
Sustained: aortic stenosis, uncontrolled hypertension.

b. Parasternal heaves:
- Place the heel of your hand over the left of the sternum with the fingers lifted slightly off
the chest, and ask the patient to stop breathing.
- In the presence of a heave, the heel will lift off the chest wall with each systole.
- Causes include:
Right ventricular hypertrophy.
Left atrial enlargement (not hypertrophy).

c. Thrill:
- A palpable murmur (like the feeling on an arteriovenous fistula).
- The site of a thrill is the same site of the valve, we detect its site by using the valve area,
i.e. mitral area, tricuspid area..etc, or by using the anatomical position, i.e. 2nd intercostal
space, 5th intercostal space... etc.

* anacrotic: one in which the ascending limb of the tracing shows a transient drop in amplitude.

*Plateau: one that is slowly rising and sustained.

*Bisferiens:A double-beat pulse palpated over the carotid or brachial arteries, which is characteristic of obstructive
cardiomyopathy and aortic regurgitation.

*alternans: one with regular alternation of weak and strong beats without changes in cycle length.

* Marfan's syndrome ; a disorder of connective tissue is caused by a defect in the gene controlling the production of
fibrillin, and is characterized by abnormal elongation of the long bones and often by ocular defects, like partial
dislocation of the lenses of the eyes, and heart defects.

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Auscultation:

- S1 and S2.
- S3 after S2 heard like a gallop rhythm:
- Physiological in children, exercising people, and hyperdynamic circulation like thyrotoxicosis
or pregnancy.
- Heard in the apex area with mitral regurgitation (MR),AR, ventricular septal defect (VSD), or
left heart failure.
- May be detected in the left lower sternal edge with right heart failure or constrictive.
- S4 after S3, and before S1 also heard like a gallop rhythm:
- May be heard at the apex area in IHD, systemic HTN, MR, or AS.
- Can be detected at the left lower sternal edge with pulmonary HTN or pulmonary stenosis
(PS).
- Murmur: a turbulent blood flow:
- Occurs with valve stenosis or regurgitation.
- It can be either systolic (comes with the pulse) or diastolic.
- It may radiates to the axilla with MR, and to the carotids with AS.
- The area of maximum intensity is the area at which the murmur is best heard.
*Grades:
1. Very soft.
2. Soft.
3. Moderate without thrill.
4. Moderate with thrill.
5 Loud.
6. Very loud, heard even without stethoscope.

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- There are special maneuvers to increase the intensity of a murmur:
a. Rightsided murmurs increase with inspiration, while left sided ones become clearer with
expiration.
b. Valsalva maneuver: expiration against closed epiglottis: helpful in mitral valve prolapse
(MVP) and hypertrophic cardiomyopathy.
c. Squatting 4-5 times: helps in MR and AS.
d. Hand grip: ask the patient to squeeze a sponge 20 times, this will magnify the murmur of
MR.

>>Types of murmurs (see page 27-28).

Techniques in auscultation:
- Start the auscultation in the mitral area using the bell to detect any low intensity murmur.
- Switch to the diaphragm and hear the whole area while you are feeling the pulse (to know
which sound is S1).
- lf the sound is very low, call it (muffled) when you present your examination.

3. Peripheral examination:

Hand:
- Clubbing*: cyanotic congenital heart disease, infective endocarditis.
- Splinter hemorrhage*: vasculitis, infective endocarditis, antiphospholipid syndrome, and
trauma.
- Cyanosis (acrocyanosis) in fingers and toes.
- Osler nodes*: infective endocarditis.
- Janeway lesions*: infective endocarditis.
- Tendon xanthomata*: occur in typeII hyperlipidemia.

Face:
- Mitral facies is rosy, flushed cheeks and dilated capillaries: associated with long standing
mitral stenosis.
Eyes:
- Pallor, jaundice.
- Xanthelasmata (patches of yellow skin around the lower or upper eyelids): type II or III
hyperlipidemia.
- Blue sclera: Marfan's syndrome.
- Arcus Senilis or corneal Arcus (Half or complete gray circle around the pupil).

* See page 10

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Mouth:
- Central cyanosis in the floor or sides of the tongue.
- Diseased teeth and petechiae are risks of infective endocarditis.
- High arched palate: Marfan's syndrome which is associated with AR or MR.

Neck:
- Carotid pulse: better to get the volume and character.
- Jugular venous pressure (JVP): >>see next figure
Stand on the right side of the patient, and focus on the site of the right jugular vein to
detect its pulsation.
lf you could not see it, put the patient on 35 then on 25and then on 10 until you see
it. If you did not, do the abdominojugular reflux test.
Abdominojugular reflux test: Put the patient on 45and press the abdomen while you
are looking to his/her neck for 10 seconds. If the pulsation of the jugular vein is still rising
and does not come back, the test is positive.
- Kussmaul's sign: rise of JVP in inspiration.

The back:
- Percussion and auscultation of the lung bases.
- Sacral edema.

The abdomen:
- Hepatomegaly.
- Splenomegaly.
- Ascites.

The lower limb:
- Lower limb edema.
- Peripheral pulses.

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How to differentiate clinically between high JVP and
visible carotid pulsation?
JVP Carotid Pulse
Visible but not palpable Palpable
2 pulses per cycle One pulse per cycle
Normally it decreases
with inspiration
Not affected by
respiration
If obliterated it fills
from above downwards
Filling from down
upwards

Note

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Types of murmurs:

a. Pansystolic, holosystolic murmurs (common):
- From S1 to S2 in same intensity.
- In MR, check for radiation, and if there is S3.
- Also present in TR and VSD.

b. Ejection systolic, mid systolic, crescendo-decrescendo murmurs (common):
- From S1 to S2 but it stops before S2.
- In AS, check for radiation.
- Also present in PS, and hypertrophic cardiomyopathy

c. Late systolic (crescendo):
- Starts actually before S2
- Presents in MVP.

d. Early diastolic (crescendo):
- In AR, check for S3.
- Also present in PR.
- It is a muffled sound.

e. Mid diastolic:
- In MS, TS, and atrial myxoma.
- In severe aortic regurgitation, the early diastolic murmur willcontinued till themid
diastolic. The murmur that is produced in such cases is called Austin Flint murmur.

f. Continuous, mechanical, musical murmurs - Both systolic and diastolic:
- Arteriovenous fistula.
- Patent ductus arteriosus (PDA)*
- Physiological in late pregnancy (mammary souffle).

..

* A heart defect that occurs when the ductus arteriosus (the temporary fetal blood vessel that connects the
aorta and the pulmonary artery) does not close at birth.

28

29

Summary

start locally from the , raecordium the p examine to you ask If your examiner
chest, then move peripherally if you have time.
Note

30

History and Examination of the Respiratory System:

Major Symptoms:

1. Cough.
2. Sputum.
3. Hemoptysis.
4. Dyspnea.
5. Wheezing.
6. Chest pain.
7. Fever.
8. Night sweats.
9. Hoarseness.
10. Hyperventilation.

Other Items in the History.

Chronic Illnesses.

Respiratory Examination:
1. Local Examination: Front.
2. Local Examination: back.

Make Positive
Statements...

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Major Symptoms:

1. Cough:
Duration:
- Acute: pneumonia.
- Chronic: asthma, COPD.
Dry cough: ACE inhibitors, interstitial lung fibrosis, gastroesophageal
reflux.
Productive cough: pneumonia, bronchiectasis.
Started as dry then became productive: complicated by pneumonia.
Awaking the patient from sleep: cardiac failure, esophageal regurgitation.
Changing in character: development of a new or serious underlying problem.
Diurnal variation.
Worsen at night: asthma, heart failure.
Immediately after eating or drinking: tracheoesophageal fistula, esophageal reflux.
Aggravating and reliving factors: dust, smoking... etc.

Causes of cough:

Acute
<3 weeks' duration
Chronic
>3 weeks' duration
Upper respiratory tract infection.
Exacerbation of COPD.
Sinusitis.
Allergic rhinitis.
Postnasal drip.
Asthma.
Gastro-esophageal reflux disease.
Lung airway disease: COPD,
Bronchiectasis, tumor, foreign body
Lung parenchymal disease:
interstitial lung disease, lung abscess
Drugs: ACE inhibitors.

32

2. Sputum:
Amount (spoon per day).
Color:
- Purulent: bronchiectasis, pneumonia.
- Dark: abscess.
- Pink frothy: pulmonary edema.
Foul smell: abscess, bronchiectasis.
Diurnal variation:
- Increased in the morning: bronchiectasis.

3. Hemoptysis (coughing up of blood):
Duration.
Amount.
Smell.
Fresh or old.
Clots or streaks.
With or without mucus.
Frequency.

33

Causes of hemoptysis:

Respiratory:
Bronchitis
Bronchial carcinoma
Pulmonary infection
Bronchiectasis
Cystic fibrosis
Lung abscess
Pneumonia
Tuberculosis
Foreign body
Goodpasture's syndrome: pulmonary hemorrhage, glomerulonephritis, antibody to
basement membrane antigen.

Cardiovascular:
Mitral stenosis (severe).
Acute left ventricular failure.

Bleeding disease.

4. Dyspnea (shortness of breath):
The awareness that an abnormal amount of work is required for breathing.
Duration.
Onset:
- Acute: pneumonia.
- Worsen progressively: pulmonary fibrosis.
- With sharp chest pain: pneumothorax.
- Varies from day to day: asthma.
Progression.
Association with chest pain, wheezing . . . etc.
Association with orthopnea and PND to exclude cardiac causes of dyspnea.
Severity: NYHA classification. (see page 17)

34

Differential diagnosis of dyspnea:
Sudden Acute: over hours Over days/months Intermittent
Upper airway
obstruction:
Asthma. Asthma. Asthma.
- Inherited foreign
body.
Pneumonia. COPD. Pulmonary
oedema.
- Anaphylaxis.
Pulmonary
oedema.
Diffuse
parenchymal
lung disease.

Pneumothorax. Extrinsic
allergic
alveolitis.
Heart failure.
Pulmonary embolism. Cardiac
tamponade.
Plural effusion.
Asthma. Cancer of the
bronchus/trachea.

Anemia.

5. Wheezing:
Maximum during expiration.
6. Chest pain:
Analyze it as a pain (back to
cardiovascular chapter).
7. Fever.
8. Night sweat:
As in TB.
Drenching sweating: the patient needs
to change cloths as they become wet.

9. Hoarseness.

10. Hyperventilation.

35

Other Items in the History

1. Past history:
Chronic illnesses (see below).
Medical:
- TB, pneumonia, chronic bronchitis, AIDS, DM.
Surgical of interventional procedures:
- Bronchoscopy, thoracoscopy, lung biopsy, spirometry, pneumonectomy, chest tube.
Bronchodilators.
Steroids treatment.
Home oxygen.
Physiotherapy (cystic fibrosis or bronchiectasis).
Oral contraceptive pills (pulmonary embolism).
Cytotoxic agent (interstitial lung disease).
ACE inhibitor, blockers, NSAID.
3. Social history:
Exposure to dust, animals, humidifiers, or air conditioners:
- Duration.
- Complications.
Smoking.
Alcoholism: aspiration pneumonia.
Exercise tolerance.
4. Family history:
Infectious diseases, e.g. TB, pneumonia.
Cystic fibrosis, emphysema.

Respiratory causes of clubbing:
- Lung cancer.
- Cystic fibrosis.
- Interstitial pulmonary fibrosis.

36

Chronic Illnesses:

1. Asthmatic patient:
When was diagnosed? Based on what?
Progressive or sustained.
How many attacks per month?
How many admission(s)?
Dose he/she admitted ever to the ICU? - How does he/she control the attack?
Dose he/she receive a corticosteroid therapy (when, why, and for how long?).
Current medications agonist, home oxygen . . . etc).
Any complications of either the illness or the treatment.

2. TB patient:
When was diagnosed? Based on which type of investigations?
Did he/she have been in the isolation? If yes, for how long?
Previous steroid use.
What is the treatment he/she receives?
Was there any improvement?
Any complications of either the illness or the treatment.

3. Patient with pulmonary embolism:
Prolonged bed rest or inactivity (including long trips in planes, cars, or trains).
Oral contraceptive use.
Surgery (especially pelvic surgery).
Childbirth.
Massive trauma.
Burns.
Cancer.
Stroke.
Heart attack (i.e. MI) - Heart surgery.
Fractures of the hips or femur.
Blood disorder.

37

Respiratory Examination

Position: sitting.
Exposure: full exposure of the trunk (if you couldn't, tell the examiner from the beginning).

1. Local examination; front:

Inspection:
Shape and symmetry:
- Barrel shaped: the AP diameter is more than transverse diameter: hyperinflation (emphysema).
- Pectusexcavatum (funnel shape); depressed sternum: Marfan' syndrome.
- Pectuscarinatum (pigeon shaped); prominent sternum: chronic pulmonary disease started at
young age, rickets.
- Harrison's sulcus: a groove (depression) in the lower edge of the chest at the insertion of the
diaphragm: long-term asthma, rickets.

Scars:
- Chest tube (tube
thoracostomy).
- Tracheostomy.
- Sternotomy.

38

Type of breathing;
- Abdominothoracic or thoracoabdominal.

Apex beat: visible or not (on the aid of torch).
Skin erythema and thickening from chemotherapy: lung cancer, lymphoma.
Subcutaneous emphysema: diffuse swelling of the chest wall and the neck: pneumothorax.

Palpation (always compare both sides):
Apex beat: can be impalpable because Of TEEDD.
- Thick chest wall.
- Emphysema.
- Effusion.
- Dextrocardia.
- Death.

Tracheal deviation: put your index and ring fingers on sternoclavicular junctions, while your
middle finger is on the trachea.
- Trachea will be pulled to the site of lesion in lung collapse, interstitial pulmonary fibrosis
(IPF).
- It will be pushed away from the site of the lesion in the presence of a tumor, pleural
effusion, or tension pneumothorax.
- Comment (if there is no deviation): trachea is centrally located.

Tracheal tug: press the trachea and ask the patient to take deep inspiration, your finger will
be pulled down in severe airway obstruction.
Tactile vocal Fremitus: ask the patient to say ''44'' or '99'.
Press on the ribs to detect any rib fracture.
Palpate the supraclavicular lymph nodes.

Chest expansions (during a deep inspiration) (see next figure ):
- Ideally, it is measured by meter over three areas: upper, middle, and lower.
- At the apex of the lung: observe the equal movement of your hand (or thumbs) up and
down.
- In the middle zone, below the nipple. See your thumbs moving apart. A space of 3-5 is
considered a good expansion.
- In the lower zone, above costal margins. Same as the middle zone.
- Comment (if it is normal): normal symmetrical chest expansion.

39

Figure 5.8: Palpation for lower lobe expansion: a) expiration b) inspiration

Percussion (always compare both sides):

Start in the supraclavicular area.
Percuss directly on the clavicles, then just below them.
Percuss in the intercostals spaces.
Percuss on the axillae and their middle zones.
Comment:
- Resonant: normal people.
- Dull (indicates consolidations): over the liver area, tumor, fibrosis, infection.
- Stony dull: pleural effusion.
- Hyperresonant: pneumothorax, emphysema.

Techniques in percussion:
- Separate your fingers from each other and press the middle finger.
- Percuss by the middle over the middle fingers 2-3 hits are more than enough.
- Don't forget to cut your nails.

40

Auscultation (always compare both sides):

- Follow the same areas of percussion.
- Switch to the bell of your stethoscope in the supraclavicular area because the sounds
are low-pitched there.
- Continue the auscultation with the diaphragm, starting from the second intercostal
space.

Type of breathing:
- Vesicular (normal breathing): inspiratory phase is longer than the expiratory one, no gap
in between, heard anywhere peripherally in the chest.
- Bronchial: inspiratory and expiratory phases are equal, with a gap in between, heard
normally over the trachea, and if there is consolidation.
- Asthmatic: expiratory phase is longer, with wheezes, and gap in between.

Added sounds:
- Wheezes are high-pitched expiratory sounds, while rhonchi are low-pitched inspiratory
sounds.
- They may present with diseases like asthma, COPD, or a lung tumor.
- Crepitations (also called crackles or rales) are inspiratory sounds, heard very clearly at
the lung base, and can be unilateral or bilateral.
- Coarse crepitation comes with consolidation.
- Fine crackles heard with fibrosis.
- Stridor is a voice that can be heard even without stethoscopes, like grasping of air,
commonly heard in children.

41

Vocal resonance:
- Ask the patient to say ''44'' or ''99''. The voice will be heard clearly with consolidation or
fibrosis, and it will be very clear with COPD.

Whispering Pectoriloquy test:
- The most sensitive test for consolidation.
- Ask the patient to whisper '' 1, 2, 3. . .etc.'', normally his/her voice will not be clear.
- In case of consolidation, the voice becomes very clear.

42

2. Local examination; back:

* The golden role: remove the scapula.

Inspection:
Shape, symmetry, and scars.
Deformities:
- Scoliosis: curved chest, or S-shaped.
- Kyphosis: K-shaped, seen from the side.
- Kyphoscoliosis both deformities together, seen in patients with poliomyelitis.

Palpation (always compare both sides):
Chest expansion.
Tactile vocal fremitus.

Percussion and auscultation (always compare both sides):
Vocal resonant.
Whispering Pectoriloquy tests.


Nails:
- Clubbing: lung cancer, fibrosis, bronchiectasis.
- Cyanosis (acrocyanosis).
- Tar or nicotine staining.

Hands and arms:
- Muscle wasting: lung tumor, especially at the apical area.
-Palmar erythema.
-Flapping tremors. Due to increased CO2 retention
-Prominent veins.
-Hypertrophic pulmonary osteoarthropathy: swelling and tenderness over the Wrist.
- Radial pulse and blood pressure.

Eyes:
- Pallor.
- Horner's syndrome: ptosis, miosis, anhidrosis (absence of sweating), and enophthalmos (a
backward displacement of the eyeball into the orbit)

Nose:
- Nasal septum deviation.
- Nasal polyps or discharge.

43

Mouth:
-Oral hygiene.
- Central cyanosis.
- Congested tonsils and pharynx.

Neck :
- Carotid and JVP.
Others:
- Sacral edema, lower limb edema, and peripheral pulses.

Trachea Chest
Expansion
Percussion Breath
sound
Added
sound
Consolidation central Dull Bronchial Course
crepitations
Asthma Central Resonant Vesicular wheezing
Fibrosis Same side Resonant Vesicular Fine
crepitations
Effusion Opposite
side
Stony dull No No
Collapse Same side Dull No No
Pneumothorax Opposite
side
Resonant No No

I
M
P

start not "respiratory examination", chest the examine to you ask If your examiner
locally from the chest, then move peripherally if you have time.
Note

44

Summary

45

History and Examination of the Gastrointestinal System:

Major Symptoms:
1. Vomiting.
2. Taste disturbance.
3. Dysphagia.
4. Heartburn.
5. Abdominal pain.
6. Abdominal distension.
7. Abdominal mass.
8. Gas and bloating.
9. Disturbed defecation.
10. GI bleeding.
11. Jaundice.
12. Postprandial fullness or early satiety.


Gastrointestinal Examination:
1. General appearance.
2. Local Examination: The abdomen.

Believe You Can..

46

Major Symptoms:

1. Vomiting:

Frequency and duration.
Timing: relation to meal, diurnal pattern.
Content: yellow, recently eaten food, old food, or blood (fresh or clotted).
Projectile or forceful.
Precedes a pain? if yes, did it relief it?
Association with nausea, fever, pain, headache or
a neural disease.

2. Taste disturbance:

Especially in liver diseases.
Duration.

3. Dysphagia:

Difficulty in swallowing.
Odynophagia: painful swallowing.
Site.
Duration.
Onset: sudden or gradual.
Persistent, intermittent, or only with the first few
swallows.
Constant or progressive (i.e. starts with solid, then with liquids).
Difficulty in initiating swallowing.
Fluid regurgitating into the nose, choking, or food sticking.
Relation to change in position e.g. increased when lying down.
History of ingestion of a foreign body, e.g. coin in children, false teeth in adults.
History of scleroderma.
Association with neck swelling (if positive, ask about symptoms of compression) food
regurgitation and cough, or recurrent chest infection.

47

4. Heartburn:
Retrosternal burning pain or discomfort.
Site and traveling upward.
Precipitating, aggravating, and relieving factors.
Relation to foods (mention the type of food).
Relation to change in position: bending, stooping, or lying supine.
Association with bitter or sour tasting coming up to the mouth (i.e. acid regurgitation).
Association with excessive salivation (i.e. water brash).

5. Abdominal pain:
Analyze it as a pain.

6. Abdominal distention:
Onset and duration.
Constant or progressive.
Association with:
Peripheral edema: heart failure, cirrhosis, nephritic syndrome .
Vomiting or constipation and which one appears first.
Pain and its frequently: to differentiate between small and large bowel obstruction.
Remember the 5 F's in generalized swelling: fat, feces, flatus, fluid, and fetus.

7. Abdominal mass:
A local abdominal distention.
Analyze it as a lump.

8. Gas and bloating:
Association with dyspepsia (Indigestion): Irritable bowel syndrome (lBS).
Recent surgery: postoperative ileus (an absence of normal intestinal function caused by a loss of
peristaltic muscular action of the intestine after surgery)

9. Postprandial fullness or early satiety.

48

10. Disturbed defecation:
It must be related to the patient's normal bowel habit.
Acute or chronic, depending on duration.
Physical appearance: color, consistency, amount, float or greasy.
Passage of blood or mucus.
Association with pain.
History of thyroid disease, inflammatory bowel disease (IBD).
Drug history.

** Definitions:
- Diarrhea: frequent stool, more than 3 times /day or change in the consistency of the stool (loose or
watery).
- Constipation: infrequent stool (less than 3 times /day) or hard stool and difficult to evacuate.
- Tenesmus: sensation in the rectum of incomplete emptying after defecation, or constant intense
desire to defecate.

11. Gl bleeding:
Amount.
Fresh or clotted.
Bright or dark.
Association with pain.

Hematemesis (vomiting blood), and melena (jet black stool):
- The presence of blood each time, or intermittent.
- History of gastroesophageal reflux disease (GERD), peptic ulcer, cancer, or liver disease.

Hematochezia (the passage of a bright red blood per rectum):
- Associated with defecation each time.
- Mixing with stool, or clearly visible (i.e. in the toilet paper).
- History of hemorrhoid, fistula, IBD, polyps, or colon cancer.

12. Jaundice:
Site of yellow discoloration.
Association with dark urine, pale stool, right upper quadrant pain, pruritus (itching of the
skin), lethargy, or fever.
History of hemolytic anemia, gallstone, or liver disease.
History of alcohol consumption, or using herbal medications.
Contact with jaundiced person.

49

Other Items in the history:

Past history:
- Past medical:
GERD, peptic ulcer, IBD, cholecystitis, pancreatitis, liver disease, Gl cancer.

- Past surgical:
GI surgery, and its complications (if happened).
Fistula: as Crohn's disease (CD) complication.
Liver transplantation.

- Past investigational or interventional procedures:
Endoscopy: colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP),
biopsy.
Reason and diagnosis.

Medication history:
- NSAID, antibiotics (especially for TB), steroids, immunosuppressants.
- Drugs that cause hepatotoxicity, e.g. paracetamol (in a large dose).
- Herbal medications.

Family history:
- IBD.
- GI cancer.
- Jaundice or liver disease.

Social history:
- History of eating from outside.
- Recent travel.
- Contact with hepatitis or jaundiced patients.
- Smoking.
- Alcohol.
- Drug abuse.

50

Gastrointestinal Examination:

Position: flat or lying on one pillow.
Exposure: ideally, from nipples to mid thighs, but expose up to the groin and tell your
examiner the ideal exposure.

1. General appearance:
Jaundice.
Weight and wasting.
Skin:
- Pigmentation. (can result from liver or renal diseases and malabsorption)
- Hereditary hemorrhagic telangiectasia.
- Porphyria cutaneatarda.(vesicles appear on exposed areas like the hands, seen in alcohol liver
disease and hepatitis C)
- Systemic sclerosis. (you see thickening of the skin, it is rare disorders associated with
gastrointestinal motility disorders)

2. Local examination of the abdomen:

Inspection:

- Symmetry: ask the patient to take deep breaths through the mouth and watch.
- Scars.
- Abdominal distension (remember the 5 F's): ascitescauses full flanks.
- Local swelling.
- Prominentveins, pulsations or peristalsis (by squatting).
- Skin lesion: rash, cautery marks, scratch marks (for pruritus), Sister Mary Joseph sign
(nodules near the umbilicus indicate umbilical metastasis).

- Skin discoloration:
Grey Turner's sign, purple discoloration of the flanks: severe acute pancreatitis.
Cullen's signs; discoloration of the paraumblilcal area: severe acute pancreatitis.
General pigmentation: Addison's disease.

- Striae:
Silver pale: obesity, pregnancy.
Purple: Cushing's syndrome, early after pregnancy.

- Condition of umbilicus:
Inverted: normal.
Everted: abdominal distension, umbilical hernia.
Semilunar (lunate): Para umbilical hernia.

51

Palpation:
A. Superficial palpation:

- For superficial masses, guarding, rigidity, or tenderness.

Guarding Rigidity
- Resistance to palpation due to
contraction of the abdominal muscles.
- May result from tenderness or anxiety.
- Protective reflex in sensitive patient.
- Voluntary or involuntary.
- Constant contraction of the
abdominal muscles.
- Always associated with
tenderness.
- Indicates peritoneal irritation.
- Pathological cause.
- Involuntary.

B. Deep palpation:
- For deep masses, e.g. a tumor, organomegaly.

Liver:
- Start at the right iliac fossa, putting your hand parallel to the right costal margin.
- With each expiration, the hand is moved 1 -2 cm closer to the right costal margin.
- Mark the lower edge of the liver by a marker or ask the patient to point it.
- Go to the right 2
nd
intercostal space, at the midclavicular line, and start to percuss, liver
dullness is usually at the 5
th
or 6
th
intercostal space.
- Measure the liver span: ''the liver is palpable... cm below the costal margin, with span of
cm.

52

- lf there is hepatomegaly you must comment on:
a) Edge: tenderness, consistency, regularity, and pulsation.
b) Surface: smooth or nodular.
c) Span: normal liver span less than 13 cm and it is more in men than women.

Gallbladder:
- Hand should be perpendicular to the costal margin, palpating from medial to lateral.
- Murphy's sign: sharp pain and cessation of inspiration (at the top of it) during palpation,
which indicates acute cholecystitis.

Spleen:
- Start from the right iliac fossa to the left hypochondrium, i.e. move obliquely.
- Identify the notch of spleen.
- lf you can't palpate it, use bimanual maneuver, role the patient to the right side and do
palpation by bimanual push at the 11
th
and 12
th
ribs area.
Kidney:
- Bimanual maneuver (ballottement).
- Not felt in normal people.

53

Techniques in abdominal palpation:
- Ask the patient if there is any tenderness in the abdomen, and examine that area at the end.
- Ask the patient to breath gently through the mouth.
- Watch the patient face when you palpate to detect tenderness.
- Don't remove your hand from the patient's abdomen.
- Start from right iliac fossa, moving clock-wise or anticlockwise, and end at the umbilical
region.
- Use the palmar surface of your fingers, but for edges or masses use the lateral surface of the
fingers because it is the most sensitive part.
- All the hand's movement should occur at the metacarpophalangeal joints.
- lf you find any mass, describe it as a lump.

Spleen Kidney
- Has no palpable upper border.
- Has a palpable notch.
- Moves inferomedially (during inspiration)
- Not ballotable
- The percussion note is dull over it.
- A friction rub may be heard over it.
- Can't get above it.
- Palpable upper border.
- No notch.
- Moves inferiorly.
- Ballotable.
- Resonant on percussion.
- No friction rub over it.
- Can get above it.

54

Percussion:

- Liver span (mentioned above).
- Spleen:
Percuss over the lowest intercostal spaces in the left anterior axillary line.
Percussion over Traube's triangle (the area where we can percuss the enlarged spleen but
still under the rib cage), which has the following boundaries:
a) Upper border: the sixth rib.
b) Lower border: the left costal margin.
c) Lateral border: anterior axillary line.
d) It overlaps the last two intercostal spaces.
* lf the spleen is enlarged 3 times or more, it will cross the midline.

- Ascites:

a) Shifting dullness (for moderate ascites):
Fingers directed downward (toward the groin).
Start percussion from the midline, and move to the left flank (away from you) When you
find the area of dullness, fix your hand, role the patient to your side, and wait for 30
seconds, then percuss again.
If the area becomes resonant, the test is positive.
For completion, continue your percussion towards the midline, until the percussion note
becomes dull.

b) Fluid thrill (for huge ascites):
Ask the patient to place one hand firmly on the center of his/her abdomen, with the
fingers pointed downward.
Flick one side of the abdominal wall. Feel the transmitted pulsations by the other hand,
which you placed it on the other side of the abdominal wall.

c) Dipping maneuver:
Using two hands for palpation in case of huge abdominal distension.

55

Auscultation:

- Bowel sounds:
Two/minute, best heard on the right lumbar and epigastric areas.
Exaggerated sounds indicate intestinal obstruction, whereas absent sounds (for 3 minutes
or more) indicate paralytic ileus.

- Friction rub:
May be audible over the liver or spleen, and indicate abnormality of the peritoneum.

- Arterial bruit:
Over the liver: hepatocellular carcinoma (HCC) .
Over renal arteries on either sides of the midline 1 cm above the umbilicus: renal artery
stenosis.

- Venous hum:
Heard between the xiphisternum and the umbilicus: portal hypertension.


Nails:

- Leukonychia: white nails due to hypoalbumonemia: liver disease.
- Clubbing*: chronic liver disease, IBD.

Palms:
- Palmar erythema: chronic liver disease.
- Pallor: anemia.
- Dupuytren's contracture*: alcoholic liver disease.
- Flapping tremor (asterixis)*: hepatic encephalopathy.

Don`t forget to say to your examiner: "I will end up the abdominal examination by PR/PV examination."
note
* See page 10

56

Arm and axilla:

- Bruising.
- Petechiae (Tiny purple or red spots on the skin).
- Muscle wasting.
- Scratch marks.
- Spider nevi (form of telangiectasis characterized by a central elevated red dot).
- Acanthosis nigricans. *
- Lymphadenopathy.

Eyes:

- Pallor.
- Jaundice.
- Iritis: IBD.
- Xanthelasma.

Mouth:

- False teeth must be removed for complete examination of the mouth.
- Oral hygiene.
- Fetor hepaticus (foul-smelling breath associated with severe liver disease).
- Mouth ulcers*: aphthous ulcer, angular stomatitis
- Gum hypertrophy, pigmentation, or candidiasis.
- The tongue:
Coating over the tongue, especially in smoked.
Lingua nigra; black tongue.
Geographical tongue.*
Leukoplakia.*
Glossitis; smooth, red, sore tongue.
Macroglossia.(Enlargement of the tongue)

Neck:
- Virchow's nodes: enlarged left supraclavicular lymph nodes.
- Troisier's sign presence of Virchow's nodes in gastric cancer patients.

Chest:
- Spider nevi.
- Gynecomastia. seen in chronic liver disease

* See next page

57

angular stomatitis: Inflammation at the corners
of the mouth.
Acanthosis nigricans :dark brownish or blackish
discoloration of the skin related to overweight and high
levels of insulin in the blood. Acanthosis nigricans is most
likely to develop in the groin or armpits, or around the back
of the neck.

Geographical tongue: A chronic inflammation of the
tongue characterized by distinct somewhat circular
groupings of lesions bounded by a white band.
Leukoplakia: A condition characterized by white
spots or patches on mucous membranes.

58

Summary

59

History and Examination of the Nervous System

Major Symptoms:
1. Brain:
Headache.
Seizure.
Fit, faint, syncope.

2. Labyrinth and vestibular nerve:
Dizziness, vertigo.

3. Head and neck:
Facial, neck, back pain.
Neck stiffness.

4. Special sense:
Vision.
Smelling.
Tasting.
Hearing.

5. Speech and swallowing.

6. Sensory:
Numbness, paraesthesia.
Loss or altered sensation.

7. Motor:
Weakness.
Involuntary movement.

8. Sphincters:
Bladder.
Bowel.
9. Gait.

Neurological examination:
1. General.
2. Cranial nerves.
3. Motor system.
4. Sensory system.
5. Gait.
6. Cerebellar examination.
Chronic illnesses.

Remember:
Your Greatest Asset
is Your "Brain"..

60

Major Symptoms:

1. Headache:
Onset and duration.
Site: unilateral or bilateral.
Radiation.
Character.
Severity: effect on daily activity and sleep.
Frequency and the duration of each episode.
Progressed or constant.
Daily pattern.
Associated symptoms: flashing, light photophobia, aura*, fever, neck stiffness, vomiting,
Jaw pain, lacrimation, eye pain, rhinorrhea, or tightness.
*Aura : a subjective sensation (as of voices or colored lights or numbness) experienced before an attack of some
nervous disorders (as epilepsy or migraine).

61

2. Seizure:
Onset, duration, and does it preceded by an aura or not.
Type (ask the patient to describe it): localized or generalized.
Frequency, severity, and how long it persists.
Comes with loss of consciousness, tongue pitting or incontinence.
How long it takes until the patient recover.
Progress or constant.
Daily pattern.
Precipitating factors: stroke, head injury, neurosurgery, brain tumor, or drugs.
Aggravating and relieving factors.
Associated symptoms: headache, nausea and vomiting.

3. Fit, faint, and syncope:
Transient loss of consciousness (also called blackout).
Onset, duration, and does it preceded by: sweating, weakness, confusion (i.e. an aura).
Frequency (previous episodes? when? what was the cause? management?), and how long
it persists.
Precipitating factors (e.g. some types of food).
Aggravating and relieving factors.
Any residual weakness?

4. Dizziness, and vertigo:
A sense of motion of the surrounding or the head itself.
Onset, duration, and how long it persists.
Frequency and how long it persists.
Precipitating factors, aggravating (e.g. by movement) and relieving factors.
Associated symptoms: headache, nausea and vomiting, pallor, sweating, deafness, or
ringing in the ear (tinnitus).

5. Facial, neck and back pain:
Site and radiation.
Onset and duration.
Character.
Severity, continuous or intermittent.
Daily pattern.

62

6. Neck stiffness:
Onset and duration.
Severity, continuous or intermittent.
Frequency.
Progress or constant.
Daily pattern.

7. Visual disturbance:
Onset and duration.
Unilateral or bilateral.
The type: blurring, double vision (diplopia), photophobia, or visual loss.
Frequency.

8. Smelling and tasting disturbance:
Onset and duration.
Frequency.

9. Hearing disturbance:
Onset and duration.
The type: tinnitus, deafness, or others.
Frequency.

10. Speech disturbance:
Onset and duration.
The type: difficulty in expression, articulation or comprehension.
Frequency.

11. Swallowing difficulty.

63

12. Sensation disturbance:
Onset and duration.
The type: numbness ''pins and needles", pain, odd sensation, or loss or altered sensation.
Frequency.

13. Motor disturbance:
Onset and duration.
The type: weakness, involuntary movement (e.g. tremor).
Frequency.
- If there is weakness, inquire about which group of muscles is affected, and if there is any
sphincter disturbance, or loss of balance.
- If it is tremor:
Rapid or slow.
Present at rest or not.
Worsens on deliberate movement or not.
History of thyroid disease.
Family history of tremor.
History of using beta-blockers.

14. Sphincters disturbance:
Onset and duration.
The type: urine, fecal, or both.
Frequency.

15. Gait disturbance:
Onset and duration.

64


1. Past history:
Past medical: Meningitis, encephalitis, epilepsy, convulsion, peripheral vascular disease, CAD,
atrial fibrillation, or coagulopathy.
Past surgical: Head or spinal injury, previous operations.

Anticonvulsants, antidepressants, contraceptive pills, antihypertensives, steroids,
anticoagulants, or antiplatelet drugs.

3. Family history:
Any neurological or mental disease.

4. Social history:
Occupation.
Exposure to toxins.
Smoking.
Alcohol.

5. Risk factors of cerebrovascular diseases:

Hypertension.
Smoking.
Diabetes mellitus.
Hyperlipidemia.
Atrial fibrillation.
Bacterial endocarditis.
Myocardial infarction.
Hematological disorder.
Family history of stroke.

65

Neurological Examination:

For complete neurological examination, follow these steps:

1. General:
Higher mental function:
- Consciousness.
- Orientation.
- Memory.
- Speech.
- Handedness.
Neck stiffness and kernig's sign.

2. Cranial nerves examination.

3. Motor examination:
Inspection.
Tone.
Power.
Reflexes.
Coordination.

4. Sensory examination:
Superficial sensation: light touch, pain, and temperature.
Deep sensation: position (proprioception) and vibration.

5. Gait.

6. Cerebellar Examination.

Remember:
Always compare the other side before moving to the next step.

66

1. General:

A. Higher mental function:

Consciousness: Note the level of consciousness:
- Conscious.
- Stupor(Mental condition marked by absence of spontaneous movement, greatly diminished
responsiveness to stimulation, and usually impaired consciousness).
- Confused.
- Comatose.

Orientation:
- Test the orientation to person, place, and time by asking the patient about his/her name,
present location and the date.
- Disorientation may be:
Delirium: acute and reversible.
Dementia: chronic and mostly irreversible.

Memory:
- Immediate memory:
By telling the patient 3 words, then after 2-5 minutes ask to recall them.
- Recent memory:
Ask the patient about what happened during the last 24 hours.
- Remote memory:
Ask the patient about something happened during the last years.

Speech:
- Ask the patient to describe the room or daily activity (in order to promote flowing speech).
Then test comprehension, e.g. "touch your chin then your nose then your ear".
- After that eliciting the language by yes and no questions.
- Then test repetition, by telling the patient a sentence and ask him/her to repeat it.
- Finally, ask the patient to name 2 objects, and to say a phrase such as "
".
- the abnormality could be:
1. Dysphasia: a dominant higher mental function disorder in the use of symbols for
communication and language. It could be:

a. Receptive (sensory or anterior) dysplasia:
Due to a lesion in Wernicke's area (posterior part of the first temporal gyrus).
Patient cannot understand the spoken (auditory dysphasia) or written word (alexia (loss
of ability to read) ).
Fluent and disorganized speech.
b. Expressive (motor or anterior) dysphasia:
Due to a lesion in Broca's area (posterior part of third frontal gyrus).
Patient understands, but cannot answer appropriately.
Non fluent speech.

67

c. Nominal dysphasia:
All types of dysphasia cause difficulty in naming objects.
Due to lesion in the temporoparietal area.
Patient cannot name objects, but other aspects of speech are normal.

d. Conductive dysphasia:
Due to a lesion in arcuate fasciculus(the bundle of axons connecting the Wernicke's area to
the Broca's area) and/or other fibers linking Wernicke's and Broca's areas.
Patient repeat statements and name objects poorly, but can follow commands.

2. Dysarthria: difficulty with articulation. It could be:
a. Spastic dysarthria:
As if the patient is trying to squeeze out words from tight lips.
Seen in pseudobulbar palsy (upper motor neuron lesion; UMNL).
b. Nasal speech:
Seen in bulbar palsy (lower motor neuron lesion; LMNL).
c. Monotonous speech:
Seen in extrapyramidal diseases, as it causes bradykinesia and muscle rigidity.
d. Slurred (scanning) speech:
Seen in alcohol intoxication, cerebellar diseases, and facial muscle weakness.

3. Dysphonia: alteration of the sound of the voice, such as huskiness of the voice with decrease
volume due to laryngeal disease, recurrent laryngeal nerve palsy or other causes.

B. Neck stiffness and Kernig's sign:

Any Patient with an acute neurological illness or who is febrile must be assessed for signs of
meningism.
With the patient lying flat in the bed, the examiner slips a hand under the occiput and gently
flexes the neck passively i.e. without any assistance from the patient.

Kernig's sign:
- It should be elicited if meningitis is suspected.
- Flex each hip in turn, then attempt to straighten the knee while keeping the hip flexed.
- This is greatly limited by spasm of hamstrings when there is meningism due to
inflammatory exudate around the lumbar spinal roots.

68

2. Cranial nerve examination :

i. Olfactory
Test each nostril separately with essence bottles of coffee, vanilla, or peppermint.
Anosmia, i.e. no smelling, it maybe uni or bilateral.
ii. Optic :
Visual acuity (by Snellens chart):
- The patient wearing his\her glasses test each eye separately.
Visual field (by confrontation method):
- Remove the patient glasses.
- Patients head should be at the level of your head, and the distance must be
approximately 50cm.
- Examine each eye separately.
- Close the patients left eye and ask him\her to look at your right eye and vice versa.
- Hold the pin at arms length, halfway between you and the patient, then bring it medially
and check the 4 quadrants and the middle field while his\her eye is looking at your eye.
Colorvision.
Funduscopy.

69

Figure 11.7 Visual field defects with lesions at various levels along the optic pathway.

*Features of Horner`s Syndrome:
Miosis, Ptosis, Anhidrosis.
* Causes of Pinpoint Pupil:
Opioids, Pontine pathology.

note

70

iii. Oculomotor (3
rd
), Trochlear (4
th
) , and Abducens (6
th
):
All muscles are supplied by oculomotor , except :
- Superior oblique, by trochlear (SO4).
- Lateral rectus, by abducens (LR6).

Assessed by testing the pupil and ocular movement :
- Pupil:
a. Size, shape, equality, and regularity.
b. Also, note if there is any ptosis, i.e. dropping of the eyelids.
- Eye movement :
a. Following the finger without moving the head: test the 6 cardinal points in (H) pattern.
b. Move your finger in (X) shape to check for superior and inferior oblique muscles.
c. Asses if there is failure in eye movement, diplopia, or nystagmus.

Light reflex:
- Afferent fibers travel with optic nerve.
- Efferent fibers come with oculomotor.
- There are direct ( intact) and indirect (consensual) light reflex:
a. Direct: the pupil constrict in the examined eye.
b. Indirect: the pupil constricts in the other eye, because they share the same nucleus
(Edinger-Westphal nuclei).

Marcus Gunn papillary sign (also called afferent papillary defect):
- Move the torch in an arc from pupil to pupil.
- If there is abnormality, the affected pupil will dilate paradoxically after a short time when the
torch moved from the normal eye to the abnormal one.

Accommodation:
- Ask the patient to look at a far object then put a pin in front of his\her eye (the distance
approximately 30cm) and observe the pupil. Normally it will constrict.
- Accommodation is controlled by the oculomotor nerve.

71

iv. Trigeminal (5
th
):

Sensory
- Ophthalmic, maxillary, and mandibular division.
- Examine it by using piece of cotton to assess light touch, and pinhead to assess pain
bilaterally.

Motor:
- Muscle of mastication: temporalis, masseter, and pterygoid.
- Inspect for muscle wasting.
- Ask the patient to clench the teeth and palpate the masseter.
- Ask the patient to open the mouth (pterygoid) and hold it open while the examiner
attempt to force if shut, and note any deviation (toward the lesion side).

Reflexes:
- Corneal reflex:
a. Lightly touch the cornea with wisp of cotton brought to the eye from the side.
b. The normal response is blinking of both eyes.
c. Ask the patient whether he\she feels the touch or not.
d. Afferent: ophthalmic division of trigeminal.
e. Efferent: facial nerve innervations of orbicularis oculi.
- Jaw reflex (masseter reflex):
a. Ask the patient to let the mouth fall open slightly.
b. Placed your index on the tip of the jaw and tapped lightly with hammer.
c. Normally there will be a slight closure of the mouth or no reaction at all.

72

v. Facial (7
th
):
Inspect for facial asymmetry, as facial palsy cause unilateral drooping of the corner of the
mouth and smoothing of the wrinkled forehead and nasolabialfold.
Muscle power (facial expression):

- Frontalis: ask the patient to look up (without moving the head)
to wrinkle the forehead.

- Orbicularis oculi: ask the patient to close his\her eyes strongly,
and try to open them.

- Buccinator: ask the patient purse lips, and try press cheeks.

- Orbicularis oris: ask the patient to smile or show teeth.

73

vi. Vestibulocochlear (auditory ) (8
th
):
Usually not performed.
Webers test Rinnes test
Technique Hold the base of a vibrating tuning fork
against the vertex.
Hold the base of a vibrating
tuning fork against the mastoid
process.
Conductive deafness Sound is louder in the affected ear,
since distraction from external sounds
is reduced in that ear.
Bone conduction is better than
air conduction.
Nerve deafness Sound is louder in the normal ear. Both bone and air conduction
are impaired.

74

vii. Glossopharyngeal and Vagus (9
th
and 10
th
).
Ask the patient to open his\her mouth to inspect the palate, then say AAH to observe the
soft palate with a torch (soft palate is pulled to the normal side).
Test for gag reflex:
- By depressing the patients tongue and touching his\her palate, pharynx or nostril.
- Compare with other side.
- Afferent is glossopharyngeal, while the efferent is the vagus.

viii. Accessory (11
th
) :
Sternocleidomastoid :
- Ask the patient to rotate head against resistance.
- Compare the power on each side.
Trapezius:
- Ask the patient to shrug shoulders and hold them in position against resistance.
- Compare the power on each side.

ix. Hypoglossal (12
th
):
Ask the patient to open his\her mouth , and inspect for :
- Atrophy: increase folds, or wasting.
- Fibrillation: small wriggling movements.
Ask the patient to protrude tongue, note any difficulty or deviation.
The tongue is deviated toward the side of weakness.

75

3. Motor system:

A. Inspection (always compare!!!):
Scars, striae, swelling, dilated vein.
Abnormal position :
- Hemiplegia.
- Mask face: Parkinson's.
- All limbs are extended: decerebration.
- Extended lower limbs, and flexed, pronated, and internally rotated upper limbs:
decortications.
Muscle wasting: caused by :
- Denervation.
- Primary muscle disease.
- Disuse atrophy.
- It can be proximal, distal, generalized, symmetrical or asymmetrical.
- Determine which muscle groups.
Abnormal movement, e.g. tremor or drifting.
Deformity:
- Wrist or foot drop.
- Claw hand.
Fasciculations:
- Irregular contraction of small areas of a muscle, which have no rhythmical pattern.
- Can be fine or coarse.
- Present only at rest.
- If it was not clear, tap on the muscle (usually biceps and brachioradialis with your
finger or a hummer), and wait for 30 seconds.

76

B. Tone (always compare):
The resistance felt by the examiner when moving a joint passively through its range of
movement.
Ask the patient to relax to allow you to move his\her joint freely ( choose the big joints).
Start from the distal then proximal or vice versa.
Note the group of muscle affected.
Normally, there is smooth minimal passive resistance.
Abnormality :
- Hypertonia: UMNL.
- Hypotonia: LMNL.
- Lead pipe and cogwheel rigidity: Parkinsonism.
- Clasp knife: UMNL.
C. Power (always compare):
The ability to make a resistance.
Tested by measuring (gauging) the examiners ability to overcome the patients full
voluntary muscle resistance.
For every joint, you have to move it in all its directions of movement.
Three normal or decreased.
Decide if it symmetrical or asymmetrical, group of muscles or general, and with pain or
not.
Grades of power(MRC grades):
- No movements (complete paralysis).
- Flickering (trying to move but there is no movement).
- Movement with gravity.
- Movement against gravity.
- Movement against gravity and resistance.
- Normal movement.

Raise the patients hand up and leave it. If it falls, the power is less than 3, but if not, apply
resistant on it.

77

The upper limb:
Shoulder:
- Adduction (C6, 7and 8) abduction (C5and 6).
Elbow:
- Flexion (C5&6) by the biceps, and extension (C7&8) by the triceps.
Wrist:
- Flexion (C6&7) and extension (C7&8).
Fingers:
- Flexion and extension (C7&8), and abduction and adduction (C8&T1).
The lower limb:
Hip:
- Flexion (L2&3), extension (L5,S1&2), abduction (L4,5&S1), and adduction (L2,3&4).
Knee:
- Flexion (L5&S1), and extension (L3&4).
Ankle:
- Planter flexion (S1&2) and dorsiflexion (S4&5).
Tarsal joint:
- Eversion and inversion (L5&S1).
Quick test of lower limbs power:
Stand on toes (S1).
Stand on heels (L4 &5).
Squat and stand again (L3&4).

78

79

D. Reflexes(always compare):
Make sure that you exposed the target muscle, and you should know the reflex roots.
If the reflex did not appear properly, apply reinforcement maneuvers:
- Upper limb reflex: ask patient to close his eyes firmly.
- Limb reflex: ask patient to pull one hand against the other.
The patient must be relaxed and properly positioned.
Grades of muscle reflex:
0 absent
+1 reduced reflex
+2 normal
+3 exaggerated
+4 exaggerated with clonus (brisk)
The upper limb:
Biceps jerk (C5&6):
- Angle of the elbow: 120.
- Place your thumb on the biceps tendon and tap your thumb with hummer.
- Normally :
a. Brisk contraction of the biceps.
b. Flexion of the forearm at the elbow, followed by prompt relaxation.
Triceps jerk(C7&8):
- Angle of the elbow 90.
- Triceps jerk with one arm flexed.
- Support the elbow with one hand and tap over the triceps tendon (do not place your
finger).
- This reflex may cause pain if you are tapping on the ulnar nerve.
- Normally there will be triceps contraction results in forearm extension.
Brachioradialis (supinator) jerk (C5&6):
- Strike the lower end of the radius just above the wrist.
- Normally there will be contraction of brachioradialis, and flexion of the elbow.
Finger jerk(C5):
- Put the patients hand upward, and flex the fingers slightly.
- Put your hand over the patients hand and strike.
- Normally the fingers will slightly flex.

80

The lower limb:
Knee reflex(patellar reflex L3&4):
- Hold the knee by your forearm.
- Tap on the patellar ligament (between patella and tibial tuberosity).
- Normally the quadriceps will contract, resulting in knee extension.
- Do reinforcement maneuvers if the reflex is poor.
Ankle reflex (S1&2):
- Both the knee and ankle are flexed 90.
- Tap on the Achilles tendon.
- Normally there will be contraction of gastrocnemius muscle causing planter flexion.
- If absent, do reinforcement maneuver.
Planter reflex (S1&2 orL5,S1&2):
- Tell the patient what will do.
- Stroke up the lateral side of the sole with a sharp instrument such as a key.
- Curve in ward before reaching the toes.
- Normally there will be a planter flexion of the big toe (downwards).

81

Babinski sign (extensor response):
- Dorsiflexion (extension or upward flexion) of the big toe, and fanning of other toes.
- Seen in UMNL lesion (pyramidal) and in infants.
- Bilateral up going toes occurs after generalized seizure, and with a patient in coma.
- Always, take the first move of the lateral toes, and if positive, never say positive, but say
extensor planter reflex.

Clonus :
- Seen in UMNL.
- Done if the patient has hypertonia (especially in ankle joint).
- Position: like ankle jerk.
- Put one hand on calf and other hand on sole and catch.
- Suddenly, do dorsiflexion of the ankleand sustain it for about 5-10 seconds. If clonus is
present, recurrent ankle planter flexion movement occurs.
- You have to do full extension and flexion of the joint to see clasp-knife spasticity if present.
- The patient must be relaxed.
- Ankle clonus: dorsiflex the ankle and observe and feel the rapid oscillation of clonus.

Patellar clonus: clasp the patella between your thumb and fingers, briskly push the patella
inferiorly. Feel for oscillation of clonus.

82

E. coordination :
limb: The upper
Finger-nose test :
- Ask the patient to touch his nose, then rotates his
finger and touch your finger (you should move his
finger from one position to another, backward
and forward as well as from side to side).
- Note any :
a. Intention tremor: tremor which increases as the
target is approached.
b. Past pointing (also called dysmetria): patient over
shoots the target.
c. Both.

Rapid alternating movement :
- Ask the patient to pronate and supinate his\ her
hand on the dorsum of the other hand as rapid as
possible.
- Inability to perform this movement smoothly is
called dysdiadochokinesis (slow and clumsy
movement) seen in cerebellar disease.
- May be affected in :
a. Extrapyramidal disease (a group of clinical disorders
marked by abnormal involuntary movements, alterations in
muscle tone, and postural disturbances e.g. Parkinsonism.)
b. Internal capsule infarction (pyramidal disease).
c. Myasthenia gravis.

Rebound phenomenon:
- Ask the patient to flex the arm at the elbow joint against your resistance.
- When you suddenly let go, violent flexion may occur and, unless prevented the
patient may strike him\herself in the face.
- Hypotonia due to cerebellar disease cause delay in stopping the arm.

83

The lower limb:
Heel shin test
- Heel: the posterior lower part of the sole, and shin: the anterior border of the tibia.
- Ask the patient to run the heel of one foot up and down the opposite shin at
moderate pace and as accurately as possible, then repeat it with closed eye.
- Inability to perform this is a sign of cerebellar disease, or posterior column loss.

Toe-finger test:
- It is not practical way to assessing.
- Ask the patient to lift the foot and touch your finger by his\her big toe.
Foot-tapping test :
- Usually not done.
- It tests rapid alternating movement of lower limb.
- Ask the patient to tape the sole of foot quickly on your hand or tap the heel on
opposite shin.
- Look for loss of rhythmicity.

84

4. Sensory system:

A. Spinothalamic pathway (pain and temperature):
Pain :
- Using a new pen or a sterile needle.
- Demonstrate the patient that this induces a relatively sharp sensation by touching
lightly a normal area, such as the anterior chest wall.
- Then ask the patient to say whether the pinprick sharp or dull.
Temperature :
- This test performed only in special circumstances, e.g. syringomyelia(a chronic
progressive disease of the spinal cord associated with sensory disturbances, muscle atrophy,
and spasticity).
- Can be done by using test tubes filled with hot and cold water.
- Ask the patient to close his\her eye .touch the patient with it and ask if it feels cold of
hot.

B. posterior column (vibration and proprioception):
Vibration :
- Using tuning fork.
- Ask the patient to close the eyes, and place the vibrating tuning fork on bony
prominence.
- The patient should be able to describe a feeling of vibration.
- Deaden the tuning fork; the patient should be able to say exactly when this occurs.
- Golden base: do not go to proximal sites unless distal site are abnormal.

C. Proprioception ( joint sensation ):
- Use the distal interphalangeal joint of the little finger or the big toe of the patient.
- When the patient opens his\her, grasp the big toe from side and move it up and
down to demonstrate these positions.
- Ask the patient to close the eyes and identify the direction of and movement.

D. Both (spinothalamic and posterior column pathway ):
- Light touch: Use a wisp of cotton and touch lightly while the patients eyes are closed,
and let him\her tell you when he\she feels the touch.

85

: Dermatomes Anatomy

86

5. Gait :

A. Make sure that the patients legs are clearly visible.
B. Ask the patient to walk normally a few meters, then turn around quickly and walk back.
C. Then ask patient to walk heel to toe, to exclude midline cerebellar lesion.

D. Some abnormal gaits:
- Hemiplegic: the foot is on planter flexion, and the leg swings in a lateral arc.
- Parkinsons: shuffling gait.
- Cerebella disease: drunken, wide based gait.
- Foot drop: high stepping gait.

E. Romberg test:
- Ask the patient stand erect with feet together and eyes open.
- Once the patient is stable, ask him\her to close the eyes.
- Note if there is unsteadiness, which indicate cerebellar or vestibular dysfunction.
- The test is positive in sensory ataxia (loss of proprioception).

87

88

6. Cerebellar examination :

This is not separate part from the previous examination, but some doctors ask examine the
cerebellum alone.
Abnormalities in cerebellar palsy indicate:
- Nystagmus.
- Dysarthria.
- Pendular knee reflex.
- Loss of coordination.
- Abnormal gait (drunken).

(it is important as an OSCE station) : Full Cerebellar Examination
1. General inspection:
Inspect the head for tremor.
Speak with the patient to assess dysarthria.
Inspect for nystagmus.
2. Upper limbs:
Inspect for obvious tremor.
Finger-nose test.
Rapid alternating movement.
Rebound phenomenon.
3. Lower limbs:
Heel-Shin test.
Toe-finger test.
Knee reflex.
4. Gait exanimation

As explained before
Note

89

Chronic illnesses :

1. stroke:
Onset and duration (how long did it last?).
Presentation: hemiplegia, loss of sensation in one half of the body, facial weakness,
hemianopia.
Management.
Complication.
Previous episode and their management.
Regular follow up in hospital.
The effect of the disease on the patients life.
Risk factor: HTN, smoking, DM, hyperlipidemia, atrial fibrillation, valvular disease, MI,
bacterial endocarditis, hematological disorder, and family history.
2. epilepsy :
When was diagnosed? Based on which type of investigation?
Type, e.g. generalized or partial.
Medication and their complication.
Number of attacks.
Regular follow up in the hospital.
Number of hospital admission due to the disease and type of management.
Progression.
Complication and indication of surgery.
The effect of the disease on the patients life.
3. Myasthenia gravis (MG):
When was diagnosed? Based on which type of investigation?
Medication, always taken or missed.
Associated with thymic hyperplasia.
Complication and their duration.
A patient usually presents with easy fatigability in proximal limb muscle, extraocular
muscle, and muscle of mastication, speech and facial expression.
4. multiple sclerosis (MS):
When was diagnosed? Based on which type of investigation (mainly MRI)?
Number of attacks.
Course of the disease: relapsing remitting, relapsing, or progressive .
Medication and their complication.
Number of hospital admission and type of management given.
Complication.

90

MS patient usually present with one or more of the following :
- Optic neuritis; blurred vision, unilateral eye pain.
- Brainstem and cerebellar dysfunction: diplopia, nystagmus, vertigo, dysphagia.
- Cognitive abnormality: failure of memory, loss of concentration, depression.
- Sensory disturbance: incontinence, frequency.
- Leg weakness.
: Important points
UMNL Hypertonia, hyperreflexia, no muscle wasting.
LMNL Hypotonia, hyporeflaxia, fasciculation and muscle wasting.
Muscle disease Wasting, hypotonia, hyporeflaxia in a particular group of muscle.
Neuromuscular
junction
disease
Generalized weakness, which worsen with repetition, normal tone
and reflex, e.g. myasthenia gravis.

91

History and Examination of the Genitourinary System

Major Symptoms:
1. Renal colic.
2. Change in urine appearance.
3. Obstructive symptoms.
4. Irritative symptoms.
5. Symptoms of uremia.
6. Systemic symptoms.

Genitourinary Examination:
1. General appearance.
2. Nails.
3. Hand and Arm.
4. Face.
5. Abdomen.
6. Back.


History of Chronic Renal Failure.

Always Have
Hope..

92

Major Symptoms:

1. Renal colic:
Analyze it as a pain.
Site, it is felt in:
- Loin: a space between the 12th rib and the iliac crest.
- Renal angle: between the 12th rib and erector spinal muscles.
Severity: sometimes constant dull ache and sometimes very sever.
It never disappears between attacks.

2. Change in urine appearance:
Could be hematuria, or any other causes such as beetroot (), paroxysmal nocturnal
hemoglobinuria, or porphyria.

In hematuria (exclude menses in a female) ask about:
- Duration.
- Gross or microscopic.
- Pain: as in stones and urinary tract infection (UTI).
- Timing of pain:
Before hematuria: stone (the patient has a history of pain for one week then he/she
developed hematuria).
After hematuria: clot colic due to arteriovenous malformation, malignancy, or other
causes.

Time in the stream:
- At the beginning: urethral causes.
- Late: trigone of the bladder, or its neck.
- Total: any site other than the bladder or the urethra.

The severity of hematuria is known by:
- The duration: the longer, the danger.
- The presence of clots, try to describe its shape.
- The color of urine: the darker the urine, the more severe the case.

3. Obstructive symptoms:
Hesitancy; difficulty starting the urine stream.
Interruption of urine.
Incomplete voiding.
Poor stream.
Straining.
Dribbling at the end, may stay many minutes after finishing the urination.

93

4. Irritative symptoms:
Frequency.
Nocturia.
Urgency, assessed by asking the patient if he/she can tolerate long distances up to the
bathroom.
Urge incontinence.

5. Symptoms of uremia:
Oliguria, nocturia, or polyuria.
Anorexia, metallic taste, vomiting, fatigue, hiccups, and insomnia.
Edema, itch, bruising, pallor, pigmentation.
Weakness, mental confusion, seizures, and coma.

6. Systemic symptoms:
Fever.
Sweating.
Loss of appetite.
Loss of weight.
Chills and rigors.
Fatigability.

94


1. Personal data:
Young female: always suspect UTI.
Old male: always suspect benign prostatic hyperplasia (BPH) and look for obstructive
symptoms.
2. Past history:
Bilharziasis.
Endoscopy, catheterization, or other invasive procedures.
Trauma.
Stones.
TB symptoms or diagnosis.
Sexual transmitted disease.
Blood disorder, HTN, DM.
Renal transplant.
Warfarin.
Heparin.
AIDS drugs.
Rifampicin.

4. Family history:
Similar illness.
TB
BPH
Any congenital disease.
5. Social history:
Smoking: the most important risk factor for transitional cell carcinoma (TCC).
Job.
Marital Status.
Sexual contact.
Travel.
Number Of relatives (for kidney donation).

95

Genitourinary Examination:

Pale (anemic), hyperventilation.
Hiccupping, uremic fetor, gray bronze skin.
Muscle twitching, tetany, epileptic seizure, subcutaneous nodule (due to calcium
deposition).
Overhydration, dehydration.

2. Nails:
Leukonychia: hypoalbuminemia, a sign of nephritic syndrome.
Muehrcke's lines; transverse opaque bands: hypoalbuminemia.
Terry's nail, half-and-half nail: chronic renal failure (CRF).
Mees' lines, a single transverse white band: acute renal failure (ARF).
Beau's lines; non pigmented indented transverse bands: any cause of catabolic
state.

3. Hand and Arm:
Anemia, asterixis, arteriovenous fistula in the waist or the forearm.
Bruising, hyperpigmentation, scratch mark (due to calcium deposition), uremic frost.
Peripheral neuropathy, myopathy, bone tenderness.
4. Face:
Eye:
- Anemia.
- Jaundice (rare): hemolysis by sodium.
- Band keratopathy: calcium deposition in the cornea.
Mouth:
- Uremic fetor.
- Mucosal ulcers.
- Oral thrush.

5. Abdomen (see abdominal examination).
inspection
- Nephrectomy scare.
- Bulge of a transplanted kidney.
- Scares for peritoneal catheters.
- Ascites (nephrotic syndrome).
Palpation:
- Enlarged kidney tends to bulge forward while the perinephric abscesses or
collections bulge backward.
- A transplanted kidney is seen in the right or left iliac fossa.
- Hepatomegaly or splenomegaly may be seen in polycystic kidney disease.
- Feel for the bladder enlargement or aortic aneurysm.
Percussion and auscultation:
- Ascites - Renal bruit.

96

6. Back:
By using a base of fist:
- Elicit tenderness over the spine: osteomalacia.
- Murphy's kidney punch, elicit tenderness over the renal angle (not too much): renal
infection.
- Sacral edema: nephrotic syndrome.

97

History of Chronic Renal Failure:

Duration.
Etiology, e.g. DM, HTN.
History of:
- Hemodialysis: when? Why? How many times? Complications?
- Arteriovenous fistula: when? Why? How many times? Complications?
- Kidney transplanted. When? Why? How many times? Complications? Donor
relationship?
- Medications: Steroids, azathioprine (Imuran), cyclosporine, sirolimus, and others.

Symptoms and complications of CRF:
- Anemia.
- Bone pain. osteomalacia, osteoporosis, secondary and tertiary hyperparathyroidism.
- CNS: motor and sensory neural impairment.
- CVS: HTN, lipodystrophy, atherosclerosis.
- Others: peptic ulcer, acute pancreatitis, hyperuricemia sexual dysfunction, and in
children, failure to thrive.

Complications of transplantation:
- Opportunistic infections.
- Premature coronary artery disease.
- Lymphomas and skin cancers.
- Complications of steroid treatment.

98

Summary

99

History and Examination of the Rheumatology System

Major symptoms:
1. Raynaud's phenomenon.
2. Red eyes.
3. Dry eyes and mouth.
4. Changes in sensation.
5. Instability.
6. Weakness.
7. Deformity.
8. Loss of function.
9. Morning stiffness.
10. Joint swelling.
11. Joint pain.

Other items in the history:

Rheumatological Examination:
1. Look.
2. Feel.
3. Move.
4. Measure.
5. special tests.

Try to eliminate
negative inputs..

100

Major Symptoms:

Joints:
- Pain.
- Swelling.
- Morning stiffness.
- Loss of function.
- Deformity.
- Weakness.
- Instability.
- Changes in sensation.

Eyes and mouth:
- Dry eyes and mouth.
- Red eyes.

Systemic:
- Raynaud's phenomenon.
- Skin rashes.
- Fever.
- Fatigue.
- Weight loss.
- Diarrhea.
- Mucosal ulcer.

101

1. Joint pain:
- Arthralgia: joint pain.
- Arthritis: joint pain and swelling.

Site and number of the affected joint(s), mono or poly.
Onset and duration.
Distribution: small or large joints.
Radiation.
Symmetry.
Additive, migratory or intermittent (important to mention the sequence):

- Additive: affects one joint then affects another one in addition to the formal one.
- Intermittent: affects the same joint, but comes and goes.
- Migratory: affects one joint, and then leaves it to another one.

Character.
Severity.
Getting better or worse.
Daily pattern.

102

Keratoderma blenorrhagica: a disease that is characterized by a scaly rash especially on the palms and soles
and is associated especially with Reiter's syndrome.

Onycholysis: a loosening of a nail from the nail bed beginning at the free edge and proceeding to the root.

Erythema nodusm: a skin condition characterized by small tender reddened nodules under the skin.

Ankylosing spondylitis (AS): is a chronic, multisystem inflammatory disorder primarily involving the
sacroiliac (SI) joints and the axial skeleton.

Reactive arthritis: acute nonpurulent arthritis complicating an infection elsewhere in the body.

Malar rash (butterfly rash): a red, flat facial rash over the bridge of the nose. Over half of patients with
systemic lupus erythematosus (SLE) develop this characteristic rash.

Poly-artharitis Oligo-artharitis Mono-artharitis
More than 4 Equal or less than 4 (4,3,2) One joint
- Affect both upper and lower
- Skin rash: malar rash, discoid
rash, Heliotrope rash
- associated with macular and
popular lesions ( vasculitis)
- Some feature of vasculitis:
splinter hemorrhage,
gangrene, oral ulcerationn
- Axial involvement is
common
- Predominant involvement
of lower limb joints
- Cutanous manifestation:
psoriatic rash, keratoderma
blenorrhagic, onycholysis
(elevation of the nails and
hyperkeratosis), erythema
nodosum, eye
(conjunctivitis, uveitis)
DDx:
- Infection: TB, Brucella
- Osteoartharitis
- Chronic malignancy
e.g: Romatoid artharitis, SLE e.g: ankylosing spondylitis,
reactive artharitis

103

2. Joint swelling:
Site.
Onset and duration.
Extension.

3. Morning stiffness:
Duration.
- Less than 30 minutes in osteoarthritis (OA).
- More than 1 hour in rheumatoid arthritis (RA).

4. Loss of function:
When and why?
What was done?

5. Deformity:
When?
Which joint?
Type of deformity.
Progression.

6. Weakness:
When?
Progression over the time.

7. Instability:
This is described by the patient as giving way or coming out.
It may be due to Joint dislocation or muscle weakness.

8. Changes in sensation:
May be due to nerve entrapment or ischemia. So, ask about:
- Numbness or paraesthesia.
- The distribution.

104

9. Dry eyes and mouth:
Characteristic of Sjogren 's Syndrome.
Duration.
Course.
Management.

10. Red eyes:
Duration.

11. Raynaud's phenomenon:
Duration.
Complication. e.g. ulcer formation.

Other items in the history:

1- Past history:

Past medical:
- Childhood arthritis.
- RA, SLE, scleroderma, vasculitis.
- Recent infection (may be relevant to the onset of arthralgia or arthritis).
- Sexually transmitted disease.
- Nonspecific urethritis and gonorrhea.
- Tick bite.
- IBD (can result in arthritis).
- Psoriasis (psoriatic arthropathy).

Past surgical:
- History of joint trauma or surgery.
Past interventional:
- Arthroscopy (examination of a joint with an arthroscope which is an endoscope that is
inserted through an incision near a joint).

Any history of physiotherapy or rehabilitation.

2- Medication history:
Antiarthritics, e.g. aspirin, NSAID, gold, methotrexate (MTX), penicillamine, chloroquine,
steroids.
Side effects: gastric ulcer or hemorrhage from aspirin.

105

3- Family history:
RA, OA.
Hemochromatosis: can result in arthritis due to calcium pyrophosphate deposition.
Seronegative spondyloarthropathies (e,g: Ankylosing Spondylitis, Reiter's Syndrome, Psoriatic
Arthritis, Arthritis of Inflammatory Bowel Disease)
IBD.
Bleeding disorders e.g. hemophilia may lead to swollen tender joints.

4- Social history:
Domestic set up.
Occupation.
Need for home assistant because of disabling arthritis.

106

Rheumatological Examination:

** Remember:
- Expose the joints that are above and below the target joint.
- Look, feel, move, measure, and special tests.
- Always compare with the opposite side.
- Joints are three dimensional structure and need to be inspected from the front, back and
the sides.

Look :
- Nails: Note any changes.
- Skin :
Atrophy.
Tightness.
Erythema: suggests an active disease.
Scars: indicate previous operation of the joint or its tendon.
Rashes, e.g. psoriatic rashes.
Discoloration.
- Muscle:
Wasting: joint disease, inflammation of the surroundings, or nerve entrapment.
- Joint:
Swelling.
Deformity.
- Bone:
Subluxation: displaced parts of the joint surfaces remain partly in contact.

Feel:
- Warmth.
- Tenderness:
Grade 1: pain.
Grade 2: pain and wince.
Grade 3: pain, wince and withdrawal.
Grade 4: patient does not allow palpation.
- Swelling:
Bony swelling: hard and immobile (osteophyte) as in OA.
Effusion: soft, spongy and fluctuated swelling occurs with RA.

107

Move:
- Passive movement: the patient lets the examiner move the joint.
- Active movement: the patient moves the joint by himself.
- During the active movement note any:
Limitation.
Instability: appreciated by asking the patient to move the joint gently in abnormal
directions.
Joint crepitus: a grating sensation or noise from the joint, which indicates chronicity.

Measure:
- Range of movement (look for the normal ranges in your book).

_____________________________________________________________________
1. Hand examination:
Position: sitting, and put the patient's hands on a pillow.
Exposure: above the elbow.

Look:
Nails:
- Pitting nails, ridging, onycholysis, hyperkeratosis: psoriasis.
- Discoloration (Raynaud's phenomenon).
- Digital infarction: scleroderma.
- Splinter hemorrhage: SLE.

Skin:
- Atrophy: chronicity.
- Tightness: scleroderma.
- Erythema: inflammation.
- Scars:
a) Rheumatoid nodule scar.
b) Fasciotomy scar in carpal tunnel syndrome.
- Rashes: psoriasis.
- Discoloration.

Muscle:
- Wasting.
- It results in the appearance of hollow ridges between the metacarpal bones.

108

Bone:
- Subluxation.
- Dislocation.
Joint swelling.

Joint deformity:
- Ulnar deviation.
- Radial deviation.
- Swan neck: hyperextension of the PIP joint and fixed flexion of the DIP joint.
- Boutonniere: fixed flexion of the PIP joint and extension of the DIP joint.
- Jaccoud's arthropathy: reversible flexion of the PIP joint and extension of the DIP joint,
seen in SLE.
- Z-deformity in the thumb: hyperextension of the IP joint, fixed flexion and subluxation of
the MCP joint.
- Sausage shape finger due to interphalangeal arthritis and flexor tendon sheath edema.
- Telescoping fingers (arthritis mutilans): shortening of the fingers.
- Resolution of finger tips (tapering fingers).

Feel:
Temperature.
Tenderness.
Swelling:
- Bony swelling:
a. Heberden's nodes: at the DIP Joint.
b. Bouchard's nodes: at the PIP joint.
(Bony bumps on the finger joint closest to the fingernail are called Heberden's nodes. Bony
bumps on the middle joint of the finger are known as Bouchard's nodes.)
- Effusion.

109

Move:
Passive movement.
Active movement, note any:
- Limitation.
- Instability.
- Joint crepitus.

110

Functions:
- Grip strength: give the patient a pen and ask him/her to squeeze it strongly.
- Key grip: the key is held between the pulps of the thumb and forefinger.
- Opposition strength.
- Practical test: ask the patient to undo a button or write with a pen.

Measure:
- Range of movement.

Special tests:

Phalen's wrist flexion test:
- lf carpal tunnel syndrome is suspected, ask the patient to flex both wrists (dorsum on the
dorsal, and the wrist should be in 90) and the patient should wait for 30 second.
- Paraesthesia will often be precipitated in the affected hand in the distribution of the median
nerve if the carpal tunnel syndrome is present.

Tinel's test:
- Tapping over the flexor retinaculum which lies at the proximal part of the palm.
- The test will be positive if there is paraesthesia in the tip of the patient's fingers.

Examination of the hands is not complete without feeling
for the subcutaneous nodules of RA near the elbow. These
nodules are firm, non-tender and found over the olecranon
or extensor surface.

111

2. Knee examination:
Position: lying down.
Exposure: both knees and thighs are fully
exposed.

Look:

Nails:
- Note any changes of the toes' nails.

Skin:
- Atrophy and tightness.
- Erythema and discoloration.
- Scars.
- Rashes.

Muscle:
- Wasting.
- Lower limb swelling due to ruptured Backer's cyst.

Joint:
- Swelling.
- Backer's cyst (a swelling behind the knee) in the popliteal fossa, while the knee in
complete extension.
- Deformity:
a. Valgus: deviation away from the midline: RA.
b. Varus: toward the midline: OA.

Bone:
- Subluxation.
- Dislocation.

Feel:

Temperature.
Tenderness.
Swelling:
- Bony swelling.
- Effusion:
a. Huge effusion: patellar tap test.
b. Moderate effusion: fluctuation test.
c. Mild effusion: milking sign.

112

Move:

Passive movement.
Active movement, note any:
- Limitation.
- Instability.
- Joint crepitus.
Measure:

Range of movement.
Strength of knee ligaments:
- Lateral and medial collateral ligaments.
- Anterior and posterior cruciate ligament.

Special tests:

Patellar apprehension test:

- Done when recurrent dislocation or subluxation of patella is suspected.
- Push the patella firmly to the lateral side while slowly flexing the knee.
- Look at the patient's face for any anxious expression that may suggest impending
dislocation.
Apley's grinding test.
Distraction test.
McMurray's test.

Finish your examination by asking the patient to walk and examine the gait.

113

History and Examination of the Endocrine System:

Major Symptoms :

1. Body weight and appetite:
2. Bowel habit.
3. Sweating.
4. Hair distribution.
5. Change in the skin.
6. Pigmentation.
7. Stature.
8. Menstruation.
9. Galactorrhea.
10. Polydipsia.
11. Polyuria.
12. Lethargy.
13. Loss of libido, or erectile dysfunction.
14. Lump in the neck.

Other Items in the History

Chronic Illnesses

History and Examination of the thyroid
gland.

Ensure you mix
with positive
people..

114

Major Symptoms:

1. Body weight and appetite:
Increased or decreased weight (more than 10% per 6 months is significant(.
Association with increased or decreased appetite.

2. Bowel habit:
Normal, diarrhea, or constipation.

3. Sweating:
Any increment.
Diurnal pattern.

4. Hair distribution:
Hirsutism.
Alopecia (Absence of hair from areas where it normally grows.).
Decreased hair distribution in a male (hypogonadism).
Increased hair distribution in a female (androgen excess).

5. Change in the skin:
Coarse, pale, and dry (hypothyroidism).
Dry and scaly (hyperparathyroidism).
Soft tissue overgrowth (acromegaly).

6. Pigmentation:
Increased: adrenal insufficiency, Cushing's syndrome, and acromegaly.
Decreased: hypopituitarism.
Localized or generalized hypo or hyperpigmentation.

7. stature:
Tall: Gigantism(abnormal growth causing excessive height), gonadotropin deficiency,
klinefelter's syndrome *,Marfan's syndrome*.
Short: dwarfism.

*Klinefelters Syndrome: a genetic disorder in which there are three sex chromosomes, XXY, rather than the
normal XX or XY.
*Marfan`s Syndrome: see page 22.

115

8. Menstruation.
9. Galactorrhea (hyperprolactinemia).
10. Polydipsia (psychogenic, hypothalamic disease...etc).
11. Polyuria (DM, Diabetes insipidus).
12. Lethargy.
13. Loss of libido, or erectile dysfunction.
14. Lump in the neck, i.e. a goiter.


Past history:

- Radioiodine treatment (hypothyroidism, hypoparathyroidism).
- Anti-thyroid drugs.
- Thyroid hormone replacement.
- Radioactive iodine.
- Surgery in the neck.

Family history:

- DM.
- Thyroid problem.
- Multiple endocrine neoplasia (MEN).
- Pituitary tumor.
- Medullary carcinoma of thyroid.
- Hyperparathyroidism.
- Pheochromocytoma and pancreatic tumor.

116

Chronic illnesses:

Acromegaly:

- Increase of growth, Soft tissue and bone overgrowth, Thick lips and separated teeth,
Bitemporal hemianopia, Thyroid enlargement, hoarseness of voice, gynecomastia,
Congestive heart failure, Organomegaly, osteoarthritis and foot drop, Hypertension.

Cushing :
- Moon face, central obesity, thin extremities, pigmentation on the extensors,
proximal myopathy, buffalo hump of the back, Psychosis, Purple striae, acne and
hirsutism, Hypertension and DM.

Addison's disease:
- Cachexia, pigmentation, vitiligo, postural hypotension.

Pheochromocytoma:
- Hypertension, pallor, palpitation, sweating, headache and anxiety, constipation,
weight loss, glucose intolerance.

Hyperparathyroidism:
- Renal stone, osteopenia, constipation, peptic ulcer, pancreatitis, confusion.

Hypoparathyroidism:
- Tetany and muscle cramp, Hyperreflexia, Dry skin, Cataract, Numbness.

117

History and Examination of the Thyroid Gland:

Thyroid history:

1. Chief complain:
Swelling in the neck or symptoms of hyper or hypothyroidism.

2. History of the presenting illness:
Swelling.
Compressing symptoms:
- Dyspnea.
- Difficulty in swallowing.
- Hoarseness of the voice when the recurrent laryngeal nerve is involved.
- Whistling of air sounds (stridor): heard when it compresses the trachea.
Symptoms of hyper or hypothyroidism (see the table below).
Risk factors:
- Exposure to radiation.
- Family history.
- Iodine intake.
- Pervious disease.

Hyperthyroidism Hypothyroidism

General
Heat intolerance, sweating, weight
loss, increased appetite, malaise.
Cold intolerance, edema, mild
obesity, weight gain.

CNS
Nervousness, irritability, insomnia,
tremor.
Psychosis, dementia, ataxia,
carpal tunnel syndrome.

CVS
Palpitation, breathlessness. HTN, heart failure,
bradycardia, pericardial
effusion.
GIT Vomiting, diarrhea. Constipation.

Musculoskeletal
Muscle weakness, proximal muscle
wasting.
Muscular hypertrophy,
proximal myopathy, myotonia.
Menstrual Oligomenorrhea ---

Eyes
Staring and protrusion eyes, lid lag,
lid retraction, ophthalmoplegia,
chemosis.
Loss of hair at the outer third
of the eyebrow.

Others

Loss of libido, gynecomastia, tall
stature in children, goiter.
Large tongue, dry thin hair,
deep voice, deafness, goiter.

118

Thyroid Examination:
Look at the general appearance if he (over dressed, sweaty, facial maxiedema)
1. Hand:
Palm (moist,. sweaty, dry) , Muscle wasting.
Tremor (fine or fast): Ask the patient to extend his/her arm with fingers straight and
separated and see from bedside, orby placing a sheet of paper over the fingers.
Feel the pulse; rate and rhythm (there may be atrial fibrillation).
2. Eyes :
Lid retraction: the upper eye retracts, Exophthalmos, Chemosis.
Lid lag: when the upper lid doesn'tkeep place with eyeball as it follows a finger moving
from abovedownwards.

3. Neck :

Inspection:
- Look to the mass.
- Ask patient to swallow and see its movement.
- Describe the swelling.
- Skin status.
- Old scar.
- Thyroid cartilage: present or not, deviated or not.
- Dilated veins due to obstruction of thoracic inlet.
- Ask the patient to put out the tongue: if the mass moves, it is most likely a thyroglossal
cyst, but if it did not, it may be a thyroid swelling.

Palpation:
a. From front:
- Size, number of masses (if nodular), surface, and edge.
- Consistency.
- Tenderness.
- Position the trachea.
b. From behind:
- Flex the neck slightly; put your thumbs behind the neck and the rest of your fingers in front to
feel the thyroid lobes.
- If the lobes are small, they are easier feel by pressing firmly on the opposite side of the neck).
- Ask the patient to swallow during palpation (Normal thyroid gland is not palpable).
- Palpate the whole neck for any cervical and supraclavicular lymphadenopathy.

119

Percussion: ( looking for mass extending)
- Over sternum.
- The clavicle.
- Supraclavicular fossa.

Auscultation :( for systolic bruit) ask the patient to take deep breath and hold it during
auscultation.

120

History and Examination of the Hematological System

Major Symptoms:

1. RBC abnormalities.
2. Platelets abnormalities.
3. WBC abnormalities.
4. Lymph nodes abnormalities.
5. Constitutional symptoms.


Chronic Illnesses.

Hematological Examination:

1. Generalappearance.
2. Hand.
3. Pulse.
4. Lymph nodes.
5. Face.
6. Bony tenderness.
7. Abdominal examination.
8. Legs.

You got a dream,
you got to protect
it..

121

Major Symptoms:

1. RBC abnormalities:
Symptoms of anemia:
- Weakness.
- Tiredness.
- Dyspnea.
- Fatigue.
- Postural dizziness.
- Pallor.
Jaundice (due to hemolysis).
Bleeding, e.g. menstrual bleeding, GI bleeding, epistaxis.

2. Platelets abnormalities:
Easy bruising, purpura, thrombotic tendency.

3. WBC abnormalities:
Recurrent infections.
Bone pain.

4. Lymph nodes abnormalities:
Lymphadenopathy.
Skin rash (lymphoma).

5. Constitutional symptoms:
Fever.
Weight loss.

Symptoms analysis:
For each symptoms above, ask about: onset duration, course (frequency,
progression, continuity), offset.
In epistaxis, ask about amount nature (fresh or clotted, bright or dark), from which
nostril (right, left or both).

122


1. Past history:
Past medical:
- Malabsorption.
- Liver disease, since it may cause coagulation abnormalities.
- Systemic disease (i.e. anemia of chronic illness), e.g. rheumatoid arthritis, renal
failure.

Past surgical:
- Gastric surgery: may cause anemia due to malabsorption.
- Venesection in polycythemia patients.

Iron supplement.
Vitamin B12 or folate supplement.
Anti-inflammatories or anticoagulants (e.g. warfarin), can cause bleeding.
Chemotherapy or radiotherapy (treatments of leukemia or lymphoma).

3. Blood transfusion.

4. Menstrual history:
Heavy menstrual loss.
Duration.
Occurrence of clots.
Number of sanitary towel (to assess the severity).

5. Family history:
Anemia.
Thalassemia.
Sickle cell.
Hemophilia.
Leukemia or lymphoma.

6. Social history:
Patient's residency: sickle cell disease common in KSA; in the East and South.
Vegetarian diet: can result in vitamin B12 deficiency.

123

Chronic Illnesses:

1. Sickle cell anemia:
Medications.
Number of hospital admissions.
Blood transfusion.
Complications:
- Hemolysis, and gallstone formation.
- Vaso-occlusion symptoms:
a. Bone pain crisis: due to avascular necrosis of the bone marrow.
b. Increase susceptibility to infection because of splenic atrophy.
c. Fits and hemiplegia: result from cerebral infarction.
d. Retinopathy and visual loss: cause by retinal ischemia.

Other complications:
- Renal failure.
- Leg ulcers.
- Acute chest syndrome: fever, cough, dyspnea, pulmonary infiltration seen in the x-ray.

2. Thalassemia:
Medications.
Number of hospital admissions.
Blood transfusion.
Complications:
- Hemolysis.
- Gallstone formation.
- Leg ulcers.
- Bone deformity.
- Abdominal distention (hepatosplenomegaly).

3. Leukemias and lymphomas:
When was diagnosed? Based on which types of investigations?
What were the first symptoms?
Treatment plan.
Complications.

124

Hematological Examination

Position: lying flat.

Looks well or ill.
Cachectic, normal, or obese.
In pain and dyspneic or not.
Cold and clammy.
Cyanosis.
Pigmentation.
Plethora.
Racial origin: thalassemia.
Pallor: anemia.
Bruising: petechiae, ecchymosis.
Jaundice: hemolytic.
Scratch marks: lymphoma and myeloproliferative disorders.

2. Hand:
Koilonychias: severe iron deficiency anemia.
Digital infarction: abnormal globulins.
Pallor of palmar creases: hemoglobin level is less than 8.1 g/dl.
Gouty tophi.
Arthropathy: hemophilia.

3. Pulse: Tachycardia.

4. Lymph nodes:
-Epitrochlear. - Axillary. - Cervical. - Supraclavicular. - Inguinal.

125

5. Face:
Eye:
- Jaundice, hemorrhage, injection.
- Conjunctival pallor: more reliable than nail beds or palmar creases for diagnosing anemia.
- Fundus examination.
Mouth:
- Hypertrophy of the gum: leukemic cell infiltration.
- Gum bleeding.
- Ulceration, infection and hemorrhage of buccal and pharyngeal mucosae.
- Atrophic glossitis: megaloblastic anemia, iron deficiency anemia.
- Waldeyer's ring enlargement: Hodgkin's lymphoma.

6. Bony tenderness:
Spine.
Sternum.
Clavicles.
Shoulders.
Enlarging marrow due to infiltration by myeloma, lymphoma or carcinoma may the cause of
tenderness.

7. Abdominal examination:
Hepatomegaly.
Splenomegaly.
Para-aortic adenopathy: lymphoma, lymphatic leukemia.

8. Legs:
Bruising.
Pigmentation.
Scratch Marks.
Palpable pleura: Henoch-schonleinpurpura.
Leg ulcer: hemolytic anemia.
Popliteal node.
Neurological abnormalities.

126

Anemia is important as an OSCE station!
Here are some points you should ask for:
- Palpitation, pallor, dizziness, SOB, fatigue.
- Bleeding, e.g. menstrual bleeding, GI bleeding,
epistaxis.
- Lymphadenopathy or weight loss.
- Menstrual history (Heavy menstrual loss!! )
- Past history: DM, HTN, IBD, malabsorption, any
other chronic diseases (liver, kidneys, heart)
- Medication: OCP, any hormonal medication, or
herbal substances.
- Family history: sickle cell, thalassemia, G6PD,
hemophilia, leukemia or lymphoma.

note

127

How to Report Your Examination?

This is just an example of reporting an examination of a normal patient. Learn it by
your heart, and try to establish you own way of reporting if you know the general
structure.

1-General examination.
2- Pericardium examination.
3-Chest examination.
4-Abdominal examination.

If we did all the things we were
capable of, we would literally
astound ourselves..
Tomas Edison

128

1. General examination:

General appearance:
- A young gentle man is lying comfortably on the bed and looking well, he is thin.
- Conscious, alert and oriented to: time, person, and place.
- Doesn't look jaundice or cyanosed or pale.
- Not on pain or respiratory distress.
- Connected to IV line of normal saline.

Vital signs:
- The blood pressure (taken from the chart or by the nurse) was.../...
- The temperature (taken from the chart or by the nurse) was ....
o

- The respiratory rate was... per minute.
- The pulse was: regular, at rate of......, No radioradial or radiofemoral delay, with good
volume and character.

The hand:
- On hand examination: there was no pallor, muscle wasting, clubbing or cyanosis.
- No signs of infective endocarditis or chronic liver disease or anemia.

The head and neck:
- On eyes: there was no pallor or jaundice.
- On the mouth: there was no central cyanosis.
- The JVP was normal, about. cm above the sternal angle.
- There was no palpable neck swelling.

Lymph nodes: No palpable lymph nodes.
Lower limbs: On examination: pulses were palpable and equal bilateral, no edema and no
clubbing.

2. Pericardium examination:
Inspection:
- There was no scares (if there is a scar, mention its site and size), or deformities.
- Apex beat is visible and seems to be in normal position, no other pulsations.

Palpation:
- The apex beat is palpable in the left fifth intercostal space medial to the mid-clavicular
line with normal character.
- No thrills or parasternal heave.

Auscultation:
- S1 and S2 were audible all over. They were normal, without any added sounds.
- lf there are any abnormalities you have to mention them.

129

3. Chest (respiratory) examination:
Inspection:
- Chest is symmetrical, no deformities and moves freely with respiration without using of
the accessory muscles, no distended veins with visible pulsations.
- Mention if there is a chest tube (for drainage).
Palpation:
- The trachea is centrally located.
- Chest is normal with bilaterally equal chest expansion and tactile fremitus is equal over
all lung fields.
Percussion:
- Bilaterally equal resonant percussion all over the lungs fields.
Auscultation:
- Normal, bilaterally vesicular breath sounds, with normal intensity, and without any
added sounds.
- Normal, bilaterally vocal resonance over all lungs failed.

4. Abdominal examination:
Inspection:
- The abdomen was symmetrical moving with respiration, umbilicus is inverted, no visible
pulsations, distended veins, or scars, hair distribution is normal, without pigmentation.
- Hernial orifices were intact (in front of the examiner ask the patient to cough).
Palpation:
- On superficial palpation, the abdomen is soft (lax) no tenderness or superficial masses.
- On deep palpation, findings were the same, and kidneys were not palpable.
- Liver span was. .... cm.
Percussion:
- Ascites was not detected.
Auscultation:
- Bowel sound was normal, no bruit over the liver, renal arteries, or aorta.
PR and PV: Were not performed.

130

EXAMPLE:

An example of a medical history
Personal details:
Mr. Frank, age 72, retired botanist.
Presenting symptoms:
3weeks of progressive exertional dyspnea with 2 days of dyspnea at rest.
History of present illness:
- Two nights of severe orthopnea; unable to sleep except briefly while sitting in a chair.
- Mild exertional shortness of breath for nearly 10 years.
- He is unable to walk 50 meters on the flat.
- Na associated chest tightness or pain.
- No wheeze or cough.
- No fever.
- No recent change in medications.
- No asthma or known lung disease. No other relevant positive symptoms on systems
review.
Cardiac history:
Previous myocardial infarction 5 years ago, treated with thrombolytic drugs.
No known valvular heart disease or history of rheumatic fever.
smoked 25 cigarettes a day until the time of his infarct.
Risk factors for heart disease:
Total cholesterol 6.7 mmol/l, a family history of ischemic heart disease, his 55year old
brother had hypertension for 30 years and inadequate control. Salt intake high, drinks 3-4
liters of fluid a day. Alcohol-25 g a week. There is no history of diabetes mellitus. Only
occasional non-steroidal anti-inflammatory drugs.
Other symptoms:
10 years of nocturia three times per night. He denies other urinary tract symptoms.
Current medications:
Aspirin, 100 mg daily, and metoprolol (a beta-blocker) 100 mg twice a day.
Past history:
Gastric ulceration 3 years ago-successfully treated with a 14 day course of antibiotics and a
proton pump inhibitor; no recurrence of symptoms.
Appendectomy and tonsillectomy in his youth.
He has no drug allergies that he knows of and has never required a blood transfusion.
Social history:
- Lives in retirement with his wife, who is well.
- Interests; gardening, history of medicinal plants, no other hobbies. No pets.
- No recent overseas travel or long car trips. No use of over-the-counter medications.

Family history:
His father died of a myocardial infarct at age 64 years, and his mother died of colon cancer
at age 84 years. Both sons (42 and 39 years) are alive and well. No other relevant family
history.

131

Physical examination:
Breathless and uncomfortable at rest.
Respiratory rate was 24 breaths/minute.
Cardiovascular:
- No cyanosis, No clubbing, No splinter hemorrhages.
- Pulse rate 90 beats/minute and regular.
- Blood pressure 180/1 10 mmHg, lying and standing.
- Temperature 37 C.
- JVP not elevated.
- Apex beat 2 cm displaced, dyskinetic.
- Heart sounds (HS): S1 (first) and S2 (second) present and normal, S3 (third) present.
- Pansystolic murmur grade 3/6 maximum at the apex consistent with mitral
regurgitation.
Chest
Trachea in the mid-line.Expansion normal right and left. Normal percussion note bilaterally.
Bilateral medium basal mid-inspiratory crackles and occasional expiratory wheeze over the
right and left lung fiends. No areas of bronchial breathing.
Well-healed appendix scar present. Abdomen soft, no tenderness.
Liver not palpable, no other masses (spleen, kidneys).
No ascites. Normal bowel sounds.
Rectal examination deferred (the patient was too unwell at the time of admission).
Legs:
No calf tenderness. No peripheral edema. Peripheral pulses present and equal. No visible
varicose veins.
Central nervous system (CNS):
Alert and orientated. No neck stiffness.
Cranial nerves (assessed after initial treatment)
- II: acuity and fields normal; fundi normal.
- III, IV and VI: pupils equal, circular and concentric-react normally to light and
accommodation; eye movements normal; no nystagmus.
- V: sensation and motor function normal.
- Vll: muscles of facial expression normal
- Vlll: hearing normal.
- IX, X: no uvular displacement.
- Xl: normal power.
- Xll: no displacement of tongue.

132

Upper limbs:
No wasting, fasciculations, tremor. Tone normal. Power normal (shoulders, elbows, wrists,
fingers). Reflexes normal and symmetrical. Coordination normal. Sensation-pain,
proprioception normal.
Lower limbs:
Gait normal. No wasting. Tone normal; no clonus. Power normal (hips, knees, ankles).
Reflexes normal and symmetrical. Coordination normal. Sensation-pain, proprioception
normal.
Provisional diagnosis:
Left ventricular failure secondary to ischemic heart disease.
Differential diagnosis:
Angina, pulmonary embolus, chronic obstructive pulmonary disease.
Investigations:
- Electrocardiogram.
- Chest X-ray.
- Full blood count Electrolytes, creatinine, liver function tests.
- Echocardiogram.

Comment:
The etiology of his cardiac failure is most likely to be ischemic heart disease (previous infarct) or
hypertensive. He has signs of mitral regurgitation, which may be secondary to cardiac failure or,
less likely, the cause. There is no known history of chronic lung disease, although he has been a
chronic smoker. The history and examination are not very suggestive of pulmonary embolism.

133

Frequently Asked Questions- Cardiovascular System

134

135

136

137

Frequently Asked Questions- Respiratory System

138

139

140

141

Frequently Asked Questions- Gastrointestinal System

142

143

144

Frequently Asked Questions- Nervous System

145

146

147

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Frequently Asked Questions- Rheumatological System

149

150

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References:

1- 424 booklet: Your Guide to History Taking and Physical Examination.
2- Nicholas Talley and Simon O`Connor, Clinical Examination, 6
th
edition.
3- Pocket Clinical Examination, Nicholas Talleyand Simon O`Connor, 3
rd

edition.
4- John Axford and Chris O`Callaghan, Medicine, 2
nd
edition.
5- Andrew Raftery and others, Differential Diagnosis, 3
rd
edition.
6- Hamad Alqahtani, Clinical Surgical Skills, 1
st
edition.

Examining the Cardiovascular System

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Second Edition 2013

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