Clinical Skills Notes

Topic Page
Overview of Physical Examination 1
Vital Sign Examination 2-5
Head & Neck Examination 6-9
ENT – Ears, Nose, & Throat Examination 10-11
Respiratory Examination 12-17
Eye Examination 18-23
Heart Examination 24-33
Lymphatic System Examination 34-35
Peripheral Vascular System Examination 36-38

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 Overview of Physical Examination
1. Start:
a) New patients: Comprehensive examination, detailed, covers all body systems & used for new patients & patients admitted to
the hospital
b) Returning patients/Specialist referral: Focused, problem oriented examination,
2. Skills:
a) Inspection: General state of health [how the patient looks],
i) General things to look for:
(1) Height, build, weight, posture
(2) Motor activity gait
(3) Grooming, personal hygiene, odors
(4) Facial expression, Manner of speaking, State of awareness
ii) Specific abnormalities:
(1) Bleeding, Beats [pulsatations]
(2) Contractures, Colors, Curvature
(3) Distribution of hair, Deformities, Deviation, Distention
(4) Size, Shape, Symmetry, Scars, Skin rash, Surface elevation, Swelling
b) Palpation:
i) Border, Beats [pulsatations]
ii) Contour, Curvature
iii) Deviations, Distension
iv) Enlargement
v) Muscle bulk, Muscle strength
vi) Range of motion, Reflex, Rigidity
vii) Tenderness, Texture, Thrills [a vibration caused by the movement of fluid felt by the examiner on palpation. Created by
turbulence in a fluid column passing through an incompetent valve, or from a vessel of smaller caliber to a larger. The
larger the orifice the bigger the thrill. Also by sharp firm percussion on one part of the abdomen and feeling a shock
wave over a distant part of the abdomen—the so-called fluid wave.]
c) Percussion:
d) Auscultation:
i) Locations:
(1) Heart: S1, S2, Murmurs, Clicks
(2) Lung: Wheezing, Coughs, Rubs, Thrills
(3) Abdomen: Obstructive bowel sounds
(4) Blood vessels: Murmurs
ii) Stethoscope: Bell of for low-pitched sounds. Diaphragm for high-pitched sounds.
3. What to test for: Quick overview, Specifics in other notes
a) Special senses: Hearing, Smell, Sight, Taste
b) Specific systems:
i) Hair, Skin, & Nails
ii) Head & Neck
iii) Ear, Nose, & Sinuses
iv) Eyes
v) Thoracic cavity & respiratory system
vi) CVS
vii) Peripheral vascular system
viii) Abdomen
ix) Musculoskeletal
x) CNS
xi) Cranial Nerves
xii) Breast
xiii) Genitourinary
xiv) Endocrine
xv) Pediatrics
xvi) Pelvis & female genitalia
c) Vital signs: Described in vital signs notes

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 Vital Signs Checklist: Pulse, Blood Pressure [B/P], Respiration [R], Temperature

1. Pulse:
a) Locations:
Arm [Antecubital Fossa]: Brachial artery Forearm: Radial & ulnar arteries Groin: Femoral artery Popliteal fossa: Popliteal
Ankle: Posterior tibial Foot: Dorsalis pedis Neck: Carotid Thorax: Apex of the heart
b) Radial pulse assessment:
i) Technique: If distal pulse not felt palpate next proximal pulse, Palpate radial artery w/ pulp of index & middle fingers 2
fingers widths proximal to crease of the wrist [vary pressure to feel for strong pulse] & count for 1minute
ii) Report: Rate, Rhythm, Character [amplitude & contour], Rigidity of vessel [best done through Osler’s maneuver during
BP measurement]
(1) Rate:
Normal: Normal 60-100 [140 in babies] Tachycardia: >100 [usually accompanies fever] Bradycardia: < 60
(2) Rhythm: Use EKG to determine rhythm if abnormal rate
Regular: Don’t use “normal” Regular irregularity: Premature atrial/ventr contraction Irregular irregularity: e.g. atrial fibrillation
(3) Character of pulse: Consists of contour & amplitude  Best observed in right carotid artery
(4) Amplitude: Crude indication of stroke volume rated from 0-4
0: Absent, not palpable 1: Diminished, barely palpable 2: Normal [expected] 3: Full & increased
(a) 0/1  Heart failure or Increased peripheral resistance
(b) 4 [Hyperdynamic circulation] Increased stroke volume [e.g. aortic regurgitation, aretriovenous fistulas, or
patent ductus areteriosis], Decreased peripheral resistance, Decreased compliance [arteriosclerosis]
(5) Contour [Waveform]: SPEED of the upstroke, the duration of the SUMMIT & the SPEED of the down stroke, Note
the effects of exercise, exertion, or breathing on the pulse
Pulsus alternans: Alternating weak & strong beat [Left ventricular Pulsus bisferiens: Biphasic pulse, 2 Strong systolic beats separated by
failure that is usually accompanied by left sided S3] mid systolic dip, AS+AR [Pure aortic regurgitation, Aortic stenosis
combined w/ regurgitation, & though not often palpable hypertrophic
cardiomyopathy]

Pulsus bigeminal: May masquerade as pulsus alternans [Normal Pulsus paradoxus [misnomer]: Exaggeration of normal fall in
beat alternating w/ premature contraction] amplitude during inspiration, Systolic BP drop >12-15mmHg, [Severe
airway obstruction [e.g. severe asthma, emphysema], Precardial
tamponade, Constrictive pericarditis]

Water Hammer Pulse/Corrigon pulse [collapsing pulse]: Greater

amplitude, Rapid rise [upstroke], Normal summit, Sudden descent
[due to backflow through aortic valve], A pulse that suddenly
collapses [Aortic regurgitation, or Patent ductus arteriosis]
c) Pulse deficit assessment: It is the difference between the heart rate by auscultation & peripheral rate by palpitation or radial
pulse [A difference &/or rapid or irregular rhythm  e.g. atrial fibrillation]
d) Radio-femoral delay: Is a delay between the time it takes for a pulse wave to reach the radial artery & femoral artery & is
assessed by palpating the radial & femoral arteries at the same time
i) Normal transmission of pulse wave to radial is 75ms & 70ms to femoral
ii) If a delay exists measure upper & lower extremity blood pressure in supine position
iii) Radio femoral delay indicates Leriche’s syndrome  Aorta or iliac atherosclerosis, Coarctation of aorta after the
subclavian artery, etc.
e) Symmetry assessment: Done by assessing on the left & right hand sides of the body at the same time & same location and can
be assessed at any of the pulse locations. If there are differences in pulses between sides it may indicate local stenosis or
compression in the path of the weaker pulse
2. Blood Pressure: Done with sphygmomanometer & stethoscope
a) Different pressure readings:
i) Systolic: Maximal pressure in the aorta during left ventricular contraction
ii) Diastolic: Lowest pressure in the aorta before left ventricular contraction
iii) Mean arterial pressure [MAP]: Normal is 93mmHg, Can be estimated by DP + 1/3 (SP-DP)
iv) Auscultatory gap: Silent interval between diastolic & systolic reading  Might lead to underestimation of systolic BP
that can be obviated by first determining pressure by palpation
v) Blood pressures: When systolic & diastolic fall under different readings use the higher category
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 Classification Systolic [mmHg] Diastolic [mmHg]
Hypotension <80
Normal <120 <80
Pre-Hypertension 120-139 80-89
Hypertension
Stage 1 [malignant] 140-159 90-99
Stage 2 [malignant] !160 100!
Isolated systolic !140 <90
Isolated diastolic !140 >90
vi) Hypotension classifications: <80 mmHg Systolic
(1) Relative: In light of past readings
(2) Absolute: Symptoms & signs of low BP exist
(3) Orthostatic: Fall of 20mmHg systolic 10mmHg diastolic on standing for 3min after recumbency
b) Preparation:
i) Patient prep: Rest for 5 minutes, Ask about consumption of caffeine, HTN medications, etc., Use are free of fistulas,
lymphedema, or severe scarring, Patient preferably seated, Preferably remove clothing from are being used
ii) Cuff size:
(1) Sizes: Normal adult, Thigh, Pediatric, Babies
(2) How to determine: Length of bladder cuff should be 80% of circumference of the upper arm, Width of bladder
should be 40% of arm circumference
iii) Cuff placement: Center arrow overlying the brachial artery above the elbow [lower 1/3 arm], Tighten cuff so that it fits
over the arm, Loose cuff will give falsely HIGH B/P reading
iv) Patient positions:
(1) Sitting: Normal position & is done with arm @ level of heart, False BP ELEVATION if arm is not supported. Other
positions
(2) Standing: Is done to check for orthostatic hypotension or autonomic insufficiency [e.g. diabetes, adrenal
insufficiency], is suspected. Wait at least 1 minute after the patient stands before taking this blood pressure & be
sure the arm is at heart level when taking it. If there is a drop of >20mmHg on standing wait then the patient has
orthostatic hypotension
(3) Supine:
c) Technique:
i) While palpating radial or brachial artery inflate cuff until pulse is no longer palpable [note this reading] & add 30mmHg
(1) Note whether the artery is still palpable [Osler’s maneuver], if it is that is called a positive Osler’s sign & is
indicative of arteriosclerosis
ii) W/ stethoscope [use bell if not audible w/ diaphragm] over the brachial artery in the ante cubital fossa & reinflate cuff to
higher level
iii) Deflate the cuff at rate of 2-3mm/sec [to avoid venous congestion wait 15seconds before reinflating]
iv) While listening with stethoscope note when 1st 2 consecutive beats heard [systolic]
v) When sounds disappear that is diastolic BP
vi) If BP is abnormal confirm by repeating 2 or 3 times
d) Complications:
i) Anxious patient: Causes BP elevation, Take 2 or more readings @ two or more visits
ii) Beats not audible: Make sure cuff is right, Use bell, Be sure patient is stable & not hypotensive
iii) Arrhythmias: Variation in BP reading [makes them unreliable], Deflate cuff slower than norm, Take several readings &
take average
3. Respiration: Requires a clock with a second hand
a) Patient preparation:
i) Rest for 3 minutes
ii) Distract patient’s attention from the activity e.g. [engaging the patient in conversation on the other subjects]
b) Technique:
i) Count respiration at the end of taking pulse while maintaining the fingers on the pulse
ii) Observe movements of chest during inspiration without making the patient being conscious of their actions for 1min
c) Report: Rate, Rhythm, Depth, Effort of breathing, Breathing patterns, Symmetry of chest movement
Normal: 14-20 breaths/minute [up to 44 for infants], Regular, quiet, barely Bradypnea: <10 breaths per minute, [Diseases affecting the CNS, Metabolic
visible, effortless disorders such as diabetic coma, Raised ICP]

Tachypnea: >24 BPM, Rapid shallow [Restrictive lung diseases, pleuritic Hyperpnea: Rapid deep hyperventilation [Exercise, Anxiety]
chest pain, elevated diaphragm e.g. intra abdominal pressure (bowel
obstruction)]

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 Ataxic: Biot’s breathing that can have unpredictable irregularity or regular Cheyne-Stokes: Shallow or deep, Rapid shallow [tachypnea], Rapid deep
irregular pattern, May be shallow or deep for a short period [Lesion in [hyperpnea], Deep alternating with periods of apnea [Damage to cerebral
lower pons or upper medulla] hemispheres (forebrain), Heart failure, Uremia, Drug induced respiratory
depression]

Prolonged expiration: Obstructive lung disease [Narrowed airway, Inspiratory cramps [Lesion to the upper pons]
resistance, to air flow, e.g. asthma, COPD]

Kussmaul breathing [labored breathing]: Is the very deep and labored Impaired or lagging respiratory movement: [Disease of the underlying
breathing with normal or reduced frequency [Found among people with lung or pleura, phrenic nerve palsy]
severe acidosis; it is a form of hyperventilation, Hyperventilation can also
be seen in midbrain damage.]

i) Symmetry of thoracic movement: If chest movement lacks symmetry it indicates underlying pathology
(1) Kyphosis: Increased curvature of upper spine
(2) Scoliosis: Patient’s spine is curved to the side
(3) Pectus: Hollowed or pigeoned chest
ii) Labored breathing: Use of accessory muscle of respiration [thoraco abdominal musculature, SCM], Nasal flaring, Supra-
clavicular retraction  Indicative of upper airway obstruction, asthma, COPD
4. Temperature: Tachycardia is observed during fever
a) Ranges:
i) Normal: 37C or 98.6F w/ diurnal variation of 0.5C between 4:00PM & 8:00PM
ii) Fever or pyrexia: >99F  Infection, Trauma, Hyperdynamic state
iii) Hyperpyrexia: >41.1C or 106F  Septicemia
iv) Hypothermia: <35C or <95F  Exposure to cold, Hypothyroidisim
b) Variations: Temperature patterns
i) Continuous: During 24hr period temp consistently above normal
ii) Intermittent: Diurnal variation, Temp fluctuates between normal & elevated over 24hr  Malaria
iii) Remittent: Abating relapsing cycles of temperature
iv) Relapsing: Alternative periods of fever & pyrexia lasting 5-7 days
c) Preparation: Avoid drinking hot or cold substances taking hot or cold showers a half hour before or very hot or cold
environments prior to measurement
d) Route & Method: Shake thermometer for mercury to come below 96F & place thermometer in location
i) Oral: Is the standard baseline  Normal 37C or 98.6F
(1) Manual: Place thermometer under tongue, Take temp for 3-5 minutes
(2) Electronic: Place thermometer under tongue, Read for 10seconds
ii) Axilla: Usually 1C lower than oral
iii) External ear canal: Place electronic thermometer in external ear canal & avoid inserting too far in, Read for 2-3 seconds
iv) Rectum: Usually 0.4-0.5C [0.9-0.9F] greater than oral. Manual: Lubricate thermometer & insert into rectum w/ patient
lying on side & hip flexed, Take temp for 5-10minutes
v) Groin:
e) Manifestations of fever:
i) Feeling cold & shivering: Denotes RISING temperature
ii) Hot & sweating: Denotes FALLING temperature
5. Clinical correlations: ↓BP w/ ↑HR = Hypovolemia

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 Head & Neck

1. Things to Examine
a) Head: Skull, Scalp, Hair, Face Skin
b) Oral cavity: Lips, Buccal mucosa, Gums & teeth, Roof of mouth, Tongue & floor, Salivary glands, Pharynx & uvula
c) Neck:
d) Ears:
e) Eyes: Described in detail later
f) Nose & Sinuses:

2. Head Examination: On examination of skull inspection & palpation can be done simultaneously
a) Scalp:
i) Inspection- look for dryness, scaliness, dandruff, and swellings (hard or soft), hygiene, lice, nits
ii) Palpation- swellings and tenderness

b) Skull: Judge size & contour, Report contusions, trauma, Depressions, Shape, Symmetry, Scars, Swelling, deformities
i) Sunken fontanelles: Indicate dehydration infants
ii) Size: Micro or macro encephaly

c) Hair:
i) Check for hair distribution & texture
(1) Baldness, patchy
(2) Hypothyroidism= it is thick, course, dry, brittle, & easily lost
(3) Hyperthyroidism= it is thin & fine
ii) Presence or absence of lice or nits [empty eggshell left by lice], Dandruff & scaliness, Swellings [hard or soft],
Hematomas, Tenderness
iii) Extra facial hair on women = maybe endocrine dysfunction

d) Face:
i) Symmetry [asymmetry might be seen in facial paralysis], scars, swellings
ii) Facial Expression [flat affect, anger, sadness]
iii) Involuntary movements [e.g. tardive dyskinesia]
iv) Deformities, lesions, edema
v) Infections, Paralysis or paresis
vi) Color change
(1) Cyanosis [Right to left shunt]
(2) Eyebrows [lateral 1/3 missing in leprosy, myxedema, & hypothyroidism]

e) Skin:
i) Color [pale, flushed]
ii) Texture, Thickness
iii) Acne
iv) Inflammation
v) Any other lesions, Hirsute [increased hair growth in women  Can indicate endocrine dysfunction], Acne, Skin cancer

3. Oral cavity: To visualize mouth, needs to be open & tongue depressed w/ tongue blade, Inspect from external to internal

a) Smell:
i) Halitosis [bad odor]: Poor oral hygiene, Bronchiectasis
ii) Fruity smell: Ketoacidosis from diabetes, etc.

b) Lips: Shape, symmetry of lips

i) Dryness or Chapping, Ulcers, Lumps, Cracks, Swelling, Bleeding
ii) Color: Cyanosis  Indicates right to left shunt
iii) Cheliosis: Cracks & sores on lips  May indicate vitamin deficiency [B2-riboflavin, cobalamin, etc.]
iv) Leukoplakia/erythroplakia: White elevated plaques that can’t be scraped off  Precancerous lesions (smokers)

c) Gums: Color, Bleeding, Cavities & fillings, Abscesses, Tenderness, hygiene

i) Gingivitis: Inflammation of the gums
ii) Periodontal disease: Inflammation of tissue that support the teeth
iii) Gum hyperplasia: Usually seen in some chronic drug use [e.g. antiepileptic drugs like phenytoin]
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 d) Teeth:
i) # of teeth: 2 Incisors, 1 Canine, 2 Pre-molars, & 3 Molars on each side
ii) Dental caries [cavity]: Infectious disease which damages tooth structure
iii) Malocclusion: Misalignment of teeth and/or incorrect relation between the teeth of the two dental arches
iv) Dental abscess

e) Buccal mucosa: Color, Pallor, Ulcers, Leukoplakia, Swellings

i) Technique: Cheek must be retraced w/ a tongue blade to visualize the mucosa
ii) Canker sores: Also called aphthous ulcers, are small, shallow lesions that develop on the soft tissues in your mouth under
your tongue, inside your cheeks or lips, and at the base of your gums. Unlike cold sores, canker sores don't occur on the
surface of your lips and aren't contagious. They can be very painful, however, and can make eating and talking difficult.
[Common in vitamin deficiencies].
iii) Inflammation, redness, ulcers, color
iv) Leukoplakia
v) (extra- ) Labii inferioris & superioris: Folds of skin in midline attaching lower & upper lips to the gums

f) Roof of mouth: Hard palate, Arch, Soft palate, Inflammation

i) Technique: This should be done by opening the mouth wide & shining a pen light towards the roof of the mouth.
ii) Torus palatinus: A bony growth on the palate. Palatal tori are usually present on the midline of the hard palate. Most
palatal tori are less than 2 cm in diameter, but their size can change throughout life, and are harmless
iii) Redness, leukoplakia, congenital anomalies (cleft palate)

g) Pharynx & uvula: Examine the posterior part of the oral cavity for pharynx & uvula, note any inflammation or redness
i) Have the patient say ‘AH’ to visualize the following:
(1) Uvula: Should move up & down & stay in the midline. Deviation indicates LMN dysfunction of CN X on the
CONRALATERAL side of the direction of deviation.
(2) Soft palate should elevate symmetrically:
(3) Look at tonsils and pillars for inflammation (usually visible in children)
(4) Examine pharynx for inflammation and redness
ii) (extra)- Gag reflex: Tested by touching pharyngeal wall w/ cotton tipped applicator. Afferent from CNIX & efferent
from CNX.
iii) (extra)- Cough reflex: Afferent & efferent from CNX

h) Tongue: (extra) Size, Shape, Color, ulcers, inflammation, wasting, Papillae, Coating, Cancer
i) Frenulum linguae: Observe veins in fold of skin below the tongue attaching it to the floor  Tears may indicate abuse
ii) Glossitis: Inflammation of the tongue
iii) Deviation of the tongue: Deviation indicates a peripheral lesion of CN XII on the same side as the direction the tongue
deviates or UMN lesion of nerves innervating the CNXII nucleus on the opposite side

i) Salivary Glands:
i) Opening of sublingual duct: Many holes in sublingual fold
ii) Parotid gland: Stenson’s duct opens opposite upper 2nd molar [a tongue blade should be used to retract the buccal
mucosa]
iii) Submandibular gland: Wharton’s duct opens as a single large caruncle near the base of the frenulum linguae

4. (doesn’t have this in notes) Neck: Hyoid bone, Jugular veins [external & internal], Cricoid cartilage, Carotid arteries, Thyroid
cartilage, Suprasternal fossa, SCM, Trapezius muscle, Clavicle, Supraclavicular fossa, Thyroid, described later
a) Anatomy:

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i)
ii) Anterior triangle boundaries: SCM [posterior], Midline [anterior], Mandible [superior], & is split into 4 smaller
triangles.

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 (1)
iii) Posterior triangle boundaries: Trapezius [posterior], SCM [anterior], Clavicle [inferior]  Inferior belly of the
omohyoid muscle splits this into to two triangles.
b) Thyroglossal cysts: Will move up when palpating the neck on tongue protrusion
c) Trachea: Palpate & observe

i)
ii) Left image  Evaluate midline position using thumbs
(1) Deviation to same side of disorder or lesion: Lung collapse
(2) Deviation to opposite side of disorder or lesion: Pneumothorax, Pleural effusion, Tumor or growth
iii) Right image  Tracheal tug [a difficult sign to elicit]
(1) Technique: Use thumb & finger to detect tracheal tugging by placing the patient in the erect position, and direct him
to close his mouth, and elevate his chin to the fullest extent, then grasp the cricoid cartilage between the finger and
thumb, and use gentle upward pressure on it. The pulsation of the aorta will be distinctly felt transmitted through the
trachea to the hand. One of the following occurrences indicates a pathological condition.
(2) Oliver’s sign: Downward displacement of the cricoid cartilage with ventricular contraction – observed in patients
with an aortic arch aneurysm
(3) Campbell’s sign: Downward displacement of the thyroid cartilage during inspiration – seen in patients with COPD

5. Lymph Nodes:
a) Technique: 2 or 3 fingers in a circular motion
b) Head:
i) Submental
ii) Submandibular
iii) Pre & post auricular
iv) Occipital
v) Tonsillar [top node anterior cervical chain  Jugulodigastric]

c) Neck:
i) Superficial cervical [patient shoulders relaxed]: Palpate superficial to SCM down the anterior border circularly
ii) Deep cervical [patient shoulders shrugged]: Palpate deep to SCM [Includes supra & infra clavicular lymph nodes]
iii) The left supra clavicular lymph node is of surgical importance [Virchow’s node  Often 1st node of metastasis in gastric
tumors]
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 iv) Posterior cervical: Palpate in posterior triangle

1. Submental 2. Submandibular 3. Parotid

4. Preauricular 5. Postauricular 6. Occipital
7. Anterior cervical 8. Supraclavicular 9. Posterior cervical
chain chain

d) Describing lymph nodes: Size, Shape, Location, Consistency, Mobility, Matted or not
i) Normal: Small, Mobile, Firm Non-tender, Discrete
ii) Inflamed: Enlarged Soft to firm, Tender, Discrete, Red on Surface [erythmatous]
iii) Cancerous: Enlarged, HARD, Non-tender, Matted, Adherent to surrounding structures [Non-motile]

6. Thyroid:
a) Relevant questions: Do you feel tired all the time?
i) Do you feel hot or cold all the time?
ii) Have you gained or lost weight recently?
iii) Have you had a changed your diet or exercise?
iv) How have your bowel movements been?
v) Check for primnence zygomatic bone, prominence of scapula

b) Peripheral signs: Have patient hold out hands to check for tremors by placing a piece of paper on their hands, hands being
turned upside down [hyperthyroidism], Exopthalamos [hyperthyroidism], Ankle reflex [relaxation will be slow in
hyperthyroidism]
c) Note: if asked to perform Thyroid gland as a MJOR skill, do all the following, INCLUDING checking for peripheral signs.
Don’t need to check for peripheral signs if it’s part of your head and neck exam
i) General- signs of weight change
ii) Eye Signs
(1) Loss of lateral third of eye brow = Hypothyroidism
(2) Lid lag- “Look at pen,” then drop the pen fast to see if one eye lid is slower than the other
(3) Lid retraction- would see the top white part of the eye (sclera) when you move pen up and down
(4) Exolphthalmos- go to pt’s back, tilt head, and look down at the level of his eyebrow. Shouldn’t be able to see eyes.
If do = exolphthalmos
(5) Extraocular muscle weakness- must perform 4 tests
(a) Corneal reflection- shine light onto eyes from front, should see reflection. If don’t = opacities, Retinoblastoma
(b) H-test
(c) Convergence (Accomodation)
(d) Cover/Uncover test
iii) Hands
(1) Tremors- paper on hands
(2) Sweating
iv) Cardiac Signs
(1) Tachycardia (will know this from checking vitals)
(2) Rhythem- Atrial fibrillation
(3) Volume- increased
(4) Murmurs- Systolic (functional)
v) Lower limbs
(1) Pretibial myxedema = Hypothyroidism
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 (2) Delayed relaxation phase of the deep tendon reflexes (say number on scale)- Hypothyroidism

d) Inspection: Use tangential lighting to observe the thyroid [isthmus & lateral lobes], Inspect during swallowing, Check for
scars, nodules, inflammation & swelling, Check for peripheral signs of hyperthyroidism
i) Just below cricoids cartilage = cricoids isthmus. It’ll move with swallowing.
ii) Look for swellings, nodules, inflammation

e) Palpation: Do the following palpations @ rest & next during swallow [thyroid cysts should move up on swallow], feel &
observe for nodules, texture, swelling, & tenderness, cancer nodules may feel firm & fixed. Ask to swallow before and while
palpating. Checking for:
i) Tenderness, size, consistency, texture, tracheal deviation
ii) First palpate below the cricoid cartilage for the isthmus of the thyroid gland
(1) Isthmus of thyroid = 3fingers below cricoids cartilage
(a) Check for tenderness, swellings, nodules
(b) Feel while swallows. Thyroglossal cyst and swellings of the thyroid will move up and down (vs other swellings
in the region)
(2) Lateral lobes of thyroid
(a) Palpation special maneuver: This maneuver will make the lateral lobe more obvious for palpation
(i) Tilt head towards side of palpation
(ii) Grab behind posterior surface of SCM & push it forward on side that the head is tilted towards
(iii) On the opposite side push the thyroid medially
(iv) Feel for size, consistency, nodules, & mobility on the side that the head is tilted towards without & with
swallowing
(v) Repeat on the other side
(vi) If you palpate a thyroglossal cyst it will move up on tongue protrusion
(b) Check for swellings and nodules and ask patient to swallow again and feel for any nodules. Cancerous nodules
will be hard

f) Auscultation: Listen for bruit [whooshing sounds]  Indicates vascular congestion in hyper vascular glands [e.g. Graves]
g) Clinical correlations: Enlargement
i) Diffuse enlargement: Grave’s disease, Hashimoto’s thyroditis, Endemic goiter [iodine deficiency], or sporadic goiter
ii) Multinodular enlargement [Enlargement w/ two or more identifiable nodules]: Usually metabolic cause
iii) Single nodule: Cyst, Benign tumor, Cancer, May only be one palpable nodule but actually a multinodular enlargement
iv) Hyperthyroidism other signs: Heat intolerance, Weight loss despite increased appetite, Bruits in thyroid
(1) Skin & Hair: Soft, warm, flushed, Excessive sweating, Fine & thin hair
(2) GI: Hypermotility, Malabsorption, Diarrhea
(3) Cardic: Palpitations, Tachycardia, Congestive heart failure [if aggravates preexisting disease], Fibrillation, Increased
volume, Murmurs
(4) Neuromuscular: Nervousness, Tremor, Irritability, 50% develop proximal muscle weakness
(5) Ocular: Wide staring gaze, Lid lag, Exophthalmoses, Lid retraction, Extra-ocular weakness
(6) Thyroid storm: Medical emergency
(7) Reflex: Delayed relaxation phase of deep tendon reflexes, Pretibial myxedema
v) Hypothyroidism other signs: Cretinism [if in early childhood], Myexdema, Generalized apathy, Mental sluggishness
[may mimic depression], Cold intolerant, Often obese, Constipation due to decreased bowel motility, Broadening &
coarsening of facial features, Tongue enlargement, Voice deepening, Pericardial effusions are common, Hair is thick,
course, dry, & brittle, Lateral one third of eybrow is lost

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 Ears, Nose & Throat

1. Ear:
a) Anatomy:

Outer ear Middle ear

b) Inspection: SSSSS, anatomical structures, Congenital anomalies, Discharge, Redness, Cysts/Sebaceous Cysts, Nodules,
Swelling, Redness

c) Palpation: Lymph nodes, tenderness

i) press tragus against ear and pull ear up or down  Pain suggests outer ear infection
ii) Press on mastoid  Pain suggests middle ear infection
iii) Tender & palpable pre & post auricular lymph nodes (palpate in rotating manner)  External ear infection

d) Speculum inspection: External auditory meatus, Auditory canal, Tympanic membrane

i) Procedure: Tilt head in opposite direction of ear being examined, Pull external ear upwards, backward & away from the
head, Hold otoscope like a pen resting extended fingers against the scalp
ii) Observe:, Cerumen, Check for perforations
(1) Patency of external auditory meatus- observe for edema of discharge
(2) Auditory canal- usually clear. Look for foreign body, cerumen
(3) Tympanic membrane
(a) Color- grey/white
(b) Structures- Handle of malleus (where maleus is in contact with membrane of ear drum), Umbo, Cone of light
(c) Abnormalities- redness, perforation, swelling, discharge

e) Hearing tests:
i) Whisper test: Whisper in each ear one word while blocking the other ear while 1 foot away from patient
ii) Weber test: Use vibrating 512Hz tuning fork & place on vertex or forehead & ask which direction sound lateralizes to
[should be heard in both ears equally]  Laterilzation to one side indicates conductive hearing loss on that side or
sensorineural hearing loss on the other
iii) Rinne test: Use vibrating 512Hz tuning fork & place against mastoid process. When patient can no longer hear fork
move it off the process and put the vibrating fork near their ear. The time for bone conduction should be less than that for
air conduction.  If not then conductive hearing loss in that ear
iv) Types of hearing loss & causes:
(1) Conductive: Foreign body in ear canal, Otitis media, Perforated ear drum, Otosclerosis, Otitis externa
12
 (2) Sensorineural: Inner ear infection, Loud noise exposure, Tumors, Trauma, Congenital, Toxicity [aspirin,
streptomycin, alcohol], Aging [presbycusis  hearing loss as you grow old], Meniere’s disease.

f) Clinical correlations: Hearing loss/Deafness [can be conductive or sensorineural], Discharge, Ear ache, Tinnitus [ringing in
ears], Vertigo
i) Perforation: Hole in the eardrum that may be central or marginal  Usually caused by otitis media or trauma
ii) Tympanosclerosis: A chalky white patch, A form of membrane thickening produced by hyalization. It results from
chronic inflammation or trauma, often in association with the insertion of ventilating tubes. Little clinical significance
iii) Red bulging drum: Otitis media [middle ear infection]
iv) Serous effusion: Amber fluid behind the eardrum w/ or w/o air bubbles  Associated w/ viral upper respiratory
infections or sudden changes in pressure [e.g. diving or flying]
v) Otitis externa: External ear infection [swimmer’s ear]
vi) Otosclerosis: Abnormal growth of bone of the middle ear. This bone prevents structures within the ear from working
properly and causes hearing loss. For some people with otosclerosis, the hearing loss may become severe.
vii) Meniere’s disease or syndrome: Result of a build-up of fluid pressure inside the inner of two fluid-filled compartments in
the inner ear, the endolymphatic system. The term Meniere's syndrome is used if an identifiable cause of this increased
pressure is present, such as syphilis, autoimmune inner ear disease, hypothyroidism, allergies, etc. The term Meniere's
disease is used if there is no identifiable cause.
viii) Myringitis: Inflammation of the ear drum
ix) Cholesteatoma: In healing perforations, epithelium of mucus membrane and squamous epithelium cover area forming
cholesteatoma
x) Exostoses: Non-tender swelling of the ear canal
2. Sinuses & Nasal Cavity:
a) Anatomy:

i)
b) Nasal Inspection: External and Internal
i) Skin color, SSSSS
ii) Discharge
iii) Perforations
iv) Septal deviation
v) Deformities

c) Nasal Patency: Tested by asking patient to press one nostril closed and asking the patient to sniff, do both sides

d) Nasal Speculum examination: DON’T TOUCH SEPTUM. Observe:

i) Turbinates = Concha. Can only see inferior, not superior or middle.

(1) Inferior meatus: drains lacrimal duct
(2) Middle meatus: Drains Maxillary, Frontal, & Anterior ethmoidal sinuses
(3) Superior meatus: Drains posterior ethmoidal & sphenoidal sinuses
ii) Vestibule for foreign bodies or polyps,
iii) Mucous membranes [normal pink color] (medial side)
iv) Nasal septum  Perforation may indicate cocaine abuse
v) Little’s area: An area on the anterior portion of the nasal septum rich in capillaries (Kiesselbach's plexus) and often the
seat of epistaxis.

e) Sinuses: Maxillary, Frontal

13
 i) Inspection: For abnormal swelling or redness
ii) Palpation: For tenderness
(1) Press on the maxillary Antrum and frontal bone near medial eye brows
iii) Trans-illumination tests: Shine light through sinuses  If light can’t be seen on other side indicates infection or
congestion of the sinuses
(1) Frontal sinus: Place light medial side below eye-brow & press ulnar surface of other hand against eyebrow to cover
the light
(2) Maxillary sinus: Ask patient to open mouth, Place light directly over the nasolabial fold & press against bone.
Observe shining pink color through mucus membrane of oral cavity
f) Clinical correlations:
i) Nasal symptoms: Rhinorrhea, Headache, Sneezing, Fever, Bleeding from nostrils, Loss of smell
ii) Nasal Disorders: Nasal polyps, Epistaxis [nose bleed  Little’s area], Anosmia [loss of smell]
(1) Rhinitis: Allergic, Infections, Drugs, Systemic diseases, Hormonal, Mucosal atrophy, Vasomotor
iii) Sinus disorders: Sinitis

14
 Respiratory

1. Anatomy:

a)

b)
2. Instruments: Stethoscope, Ruler, Penlight
3. Order: Inspect, Palpate, Percuss, Auscultate
4. Peripheral signs of respiratory dysfunction:
a) Nose: Patency of nostrils, Septal deviation, Color of mucus membrane
b) Oral cavity:
i) Cyanosis: Right to left shunt
ii) Halitosis [bad odor]: Poor oral hygiene, Bronchiectasis
iii) Hoarseness of voice: Laryngitis
iv) Pursed lip breathing: COPD e.g. [Emphysema]
c) Hands:
i) Clubbing:
(1) Hypertrophy of angle between nail base & finger:
Angle between nail-base & finger is obliterated
[normally less than 180 degrees]
(2) Beak shaped/ Drum-stick appearance
(3) Tissues at the base of the nailbed are thickened
(4) Cardiac causes: Bacterial endocarditis, Cyanotic
congenital heart diseases,
(5) Pulmonary causes: Lung cancer, Empyma, Cystic
fibrosis, Fibrosing alveolitis,
(6) GI causes: Inflammatory bowel diseases [Chron’s
disease, Ulcerative colitis], Cirrhosis
(7) Congenital:
(8) Idiopathic:

15
 ii) Pigmentation:
d) Eyes:
i) Horner’s syndrome: Apical lung tumor impinging sympathetic chain
ii) Anemia  Indicated by palpebral conjunctival pallor
e) Neck:
i) Engorgement of veins  Indicates pulmonary RHF
ii) Supraclavicular lymph nodes  e.g. metastasis or infection
iii) Contraction of platysma & SCM  Use of accessory muscles of respiration, e.g. emphysema
f) Body:
i) Asterixis: Is a tremor of the wrist when the wrist is extended (dorsiflexion), sometimes said to resemble a bird flapping
its wings
ii) Cachexia: Loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite in someone who is not
actively trying to lose weight.  E.g. emphysema
iii) Leg edema: Signs of right heart failure
iv) Respiratory distress: Purse lip breathing, Retraction of intercostals muscles, Contraction of platysma & SCMs during
breathing
g) Cyanosis:
i) Peripheral  Shock
ii) Central  Arterial hypoxemia, Heart & lungs
h) Trachea: Inspect for deviation [specific tests described in head & neck]
5. Breathing: Discussed in vital signs
6. Trachea: Discussed in head & neck
7. Inspection: Remember the 5 S’s, Shape, Symmetry, Size, Swelling, Scars
a) Anterior Inspection: Shape & symmetry of chest, Chest expansion, Slope & position of ribs [usually oblique], Intercostal
recession [obstructed airway], Accessory muscle of respiration, Apical impulse, Impaired or lagging respiratory movement
[disease of the underlying lung or pleura, phrenic nerve palsy]
i) Surface markings: Nipples, Manubriosternal junction, Suprasternal notch, Vertebral prominens, Clavicles, Inferior angle
of scapula-At the level of 7th rib or interspace
b) Posterior Inspection: Shape & symmetry of thorax, Chest expansion, Slope of ribs, Intercostal recession [obstructed airway],
Accessory muscle of respiration, Vertebrae [abnormal  e.g. kyphosis or scoliosis]
c) Shape:

16
 d) Symmetry of chest movement during breathing can indicate underlying pathology
8. Palpation both anterior & posterior: Masses, Tenderness
a) Anterior palpation: Cardiac impulse
b) Measurement of AP & Lateral diameters: Thorax in normal adult is wider than it is deep
i) AP diameter: Distance between anterior and posterior axillary lines
ii) Lateral diameter: Distance between anterior axillary lines on front
iii) AP to Lateral ratio: Normally ratio is 1:2 or 5:7
c) Tactile fremitus: Ask the patient to say “99” & feel for vibrations with ball [ulnar border] of your hand,
i) Increased tactile fremitus: Consolidation
ii) Decreased tactile or absent fremitus: Pleural effusion

Anterior locations Posterior locations

d) Chest excursion: Feel & ask patient to inspire & feel how the ribs move
Anterior locations: Posterior locations
Check expansion of [Perform in 3 locations]:
chest by keeping both 1. Above scapula
your hands on chest 2. Between scapula
holding fold of skin 3. Below scapula
between thumbs in
midline. Observe
symmetrical expansion
of chest in three
positions including
costal margin, level at
nipples and below
clavicles.
9. Auscultation & Percussion:
a) Locations:

Anterior locations Posterior locations

b) Percussion: Means to tap the surface to determine underlying structures. Sounds travels to the underlying tissues through
chest wall and reflects back & is picked up by the examiner. Different areas produce different sounds. Over heart & solid
organs the sound is dull.
i) If right handed, place the middle finger of the LEFT hand on the surface you are going to percuss, this is known as the
pleximeter finger.
ii) Middle finger of right hand you tap with your plexor finger.
iii) Movement is at the wrist

17
 iv) Technique:
v) Sounds: Normally in thorax you will hear resonance [exclude cardiac & liver dullness], Sounds listed below
(1) Flatness or absence: Pleural effusion
(2) Dullness: Essentially any condition that decreases the amount of air in the lungs [e.g. Pneumonia, Lung collapse,
Pleural effusion]
(3) Resonance: NORMAL
(4) Hyperresonance: Essentially any condition that increases the amount of air trapped in the lungs [e.g. Emphysema,
Pneumothorax Chronic bronchitis], Normal cardiac dullness may ALSO disappear
(5) Tympany: Gastric air bubble, Large pneumothorax
vi) Diaphragmatic excursion: Can be used to find level of diaphragm during inspiration & expiration by listening to changes
in percussion [it will become dull when you get to the diaphragm]
(1) Percuss chest during expiration starting from the tip of the scapula & working down [mark the level]
(2) Percuss again during deep inspiration starting from the tip of the scapula & working down [mark the level]
(3) The distance between the two points should normally be 4-6cm
(4) Measure on both front & back
(5) The distance will be decreased in phrenic nerve paralysis & pleural effusions
c) Auscultation: Use diaphragm of stethoscope
i) Vocal fremitus: Ask the patient to say “99” & listen for vibrations w/ stethoscope
(1) Increased vocal fremitus: Consolidation
(2) Decreased or absent vocal fremitus: Pleural effusion
ii) Breathing types: Ask patient to take deep breaths

iii)
Type & Shape Description Volume Region
Vesicular Inspiratory sounds last longer than Soft Over most of the lungs
expiratory
Bronchovesicular Inspiratory sounds & expiratory sounds Intermediate Angle of Louis & between scapulae
last the same amount of time
Bronchial Expiratory sounds last longer than Loud Over manubrium & sternum
inspiratory
Tracheal Inspiratory sounds & expiratory sounds Very loud Over trachea & in neck
last about the same amount of time
iv) Breath Sounds: Generally breath sounds will be INCREASED in regions of consolidation

18
 (1) Continuos: Wheezing [high-pitched continuous, musical sounds heard in respiratory diseases.] or Rhonci [low-
pitched coarse rattling sound somewhat like snoring, usually caused by secretions in bronchial airways], Musical
prolonged
(2) Discontinuous/Intermittent: Crackles or Rales [discontinuous, intermittent, nonmusical and brief sounds in
respiratory and cardiac diseases]
(3) Fine/coarse: Pleural rub [Grating sounds during inspiration and expiration], Nonmusical brief:
(4) Reduced or absent: Essentially any condition that will reduce the amount of air entering & exiting the lung [e.g.
Pneumothorax, Pleural effusion, Emphysema, Lung collapse, Chronic bronchitis]
v) Bronchopony: The patient is requested to repeat a word several times (the numbers "ninety-nine" or "sixty-six" are
traditional) while the physician auscultates symmetrical areas of each lung. Normally, the sound of the patient's voice
becomes less distinct as the auscultation moves peripherally; bronchophony is the phenomenon of the patient's voice
remaining loud at the periphery of the lungs or sounding louder than usual over a distinct area of consolidation (such as
pneumonia). This is a valuable tool in physical diagnosis used by medical personnel when auscultating the chest.
vi) Whispered pectorliquy: Ask patient to whisper “99” & listen for low pitched & indistinct sounds. When it is whispered
sounds are usually NOT heard. If you hear sounds it indicates a region consolidation.
vii) Egophony: Ask patient to say ‘ee’ & you will normally hear a muffled long E. If what is heard is a higher pitched sound
that sounds like the letter "a." (Some doctors refer to this as "e to a changes."). This indicates a region of consolidation
[e.g. pneumonia].
10. Clinical correlations: No details listed, Just the diseases
a) Dyspnea causes:
i) Acute onset: Pulmonary embolism, Pulmonary edema, Pneumothorax
ii) Short onset: Pulmonary edema, Asthma
iii) Chronic condition: COPD, Anemia, Fibrosing alveolitis
b) Hemoptysis causes:
i) Respiratory: Carcinoma, Pulmonary infarct, Bronchitis, Bronchiectasis, Cystic fibrosis
ii) Cardiac: Mitral stenosis
iii) Other: Bleeding disorders
c) Bronchopneumonia: Reduced chest expansion, Tactile fremitis increased on affected side, Percussion is dull, Breath sounds
are bronchial in nature, Additional sounds such as rales, Vocal fremetis increased on affected side, May hear pleural rub,
Egophony will show “e” to “a” change in affected region, Whispering pectoriloquy will result in sounds in affected region
d) Bronchial asthma: Wheezing, Tachynea, Tachycardia, Prolonged expiration, Use of accessory muscles, Hyperinflated chest
e) Lung collapse: Trachea displaced to collapsed side, Dull percussion, Breath sounds reduced
f) Bronchiectasis: Fever, Cachexia, Sinusitis, Clubbing, Cyanosis, Sputum is voluminous, purulent, & foul smelling, Course
inspiratory crepitations
g) Emphysema: Barrel shaped chest, Pursed lip breathing, Use of accessory muscles, Reduced expansion on palpation,
Percussion will show hyperresonance, Breath sounds decreased, Signs of heart failure
h) Chronic bronchitis: Cough, Sputum, Cyanosis, Palpation shows reduced expansion, Percussion shows hyperresonance,
Breath sounds are decreased w/ wheezing & inspiratory crackles, Sings of right heart failure
i) Pleural effusion: Trachea & apex beat displaced away from massive effusion, Reduced expansion on palpation, Dullness on
percussion, Breath sounds are decreased, Vocal & tactile fremetis decreased on affected side
j) Pneumothorax: Reduced expansion on palpation, Hyperresonance on percussion, Breath sounds reduced or absent,
Subcutaneous emphysema
k) Tension pneumothorax: Tachypneic, Cyanotic, Hypotensive, Trachea & apex beat displaced away from affected side,
Reduced expansion on palpation, Hyperrosanance on percussion, Breath sounds absent, VR reduced
l) Bronchogenic carcinoma: Hemoptysis, Clubbing, Lobar collapse, Pneumonia, Pleural effusion [usually bloody], Fixed
respiratory wheeze, Mediastinal compression, Tender ribs, Lymphadenopathy
m) Pulmonary embolism: Tachycarida, Tachypnea, Fever, Pleural friction rub, Elevated JVP, Right ventricular gallop, Right
ventricular heave, Tricuspid regurgitation murmur, Increased pulmonary component of 2nd heart sound

19
 Eye Examination

1. Anatomy:

a)
2. Initial Assessment: With the patient seated facing the examiner at about two feet away at the same level
a) Examine the eyes and orbits: Size, Shape, Symmetry, Scars, Swellings.
i) Periorbital edema  Where edema due renal failure first manifests
b) Eyebrows for hair: Distribution & Lesions
i) Loss of the lateral one third: Suggests Hypothyroidism, Leprosy, or Myxedema
c) Shine the penlight at the eyes directly from about two feet:
i) Assess the symmetry of the highlights reflected from each cornea
ii) Reflection should be in the nasal field of each eye  If it is not then this indicates an extraocular muscle dysfunction
3. Eyelids: Check the eyelids for, Position, Swelling, Redness, & Lesions
a) Position: If lowered then ptosis  Indicative of Horner’s syndrome
b) Exopthalamos  Indicative of hyperthyroidism [it is observed from above]
c) Eye lashes: Top lid has 2 rows & bottom lid has 1 row
d) Direction: Ectropion [eye lid turned out] & Entropion [eye lid turned in]
e) Cant close: Facial nerve palsy
f) Can’t open: CN III nerve palsy
g) Lesions:
Chalazion: Beady nodule in either eyelid Sty: A pimple like infection around a Blepharitis: Inflammation of eyelids
caused by chronically inflamed meibomian hair follicle near the lid margin making them red, irritated, itchy, &
gland formation of dandruff-like scales on
eyelashes.

h) Xanthelasma: Sharply demarcated yellowish collection of cholesterol underneath the skin, usually on or around the eyelids

i)

20
4. Conjunctiva: Pull the lower eyelid down and assess the palpebral (palor) and bulbar conjunctiva (hemorage) for Color,
Pigmentation, Swelling, Inflammation, & Growths such as a pingueculum or a pterygium
a) Color: If excessively pale  Indicates anemia
Pingueculum: A yellowish patch or bump on the white of the eye, most often on the side
closest to the nose. It is not a tumor, but an alteration of normal tissue resulting in a deposit
of protein and fat. Unlike a pterygium, a pingueculum does not actually grow onto the
cornea. A pingueculum may also be a response to chronic eye irritation or sunlight.

Pterygium: A fleshy growth that invades the cornea. It is an abnormal process in which the
conjunctiva (a membrane that covers the white of the eye) grows into the cornea. Pterygium
may be small or grow large enough to interfere with vision, and commonly occurs on the
inner corner of the eye. The exact cause of pterygium is not well understood. Pterygium
occurs more often in people who spend a great deal of time outdoors, especially in sunny
climates. Long-term exposure to sunlight, especially ultraviolet (UV) rays, and chronic eye
irritation from dry or dusty conditions seem to play an important causal role.

Chemosis: Swelling of the tissue that lines the eyelids and surface of the eye (conjunctiva).

Subconjuctival hemorrhage:

5. Lacrimal Apparatus:
Anatomy: Sjogren's syndrome: Dacryocystitis: Epiphora:

Sjögren's ("SHOW-
grins") syndrome is a An overflow of tears, usually
chronic disease in Infection of the tear sac caused by poor drainage of
which white blood between inner corner of the tear film from the eye.
cells attack the eyelids and nose. Usually Most common cause is block
moisture-producing caused by block of the duct of lacrimal ducts. May also
glands that carries tears from the result from excessive tearing.
tear sac to the nose.
Dacroadenitis is lacrimal
gland enlargement.
a) Method:
i) Look at the upper lateral orbital margin for any swelling of the lacrimal gland
ii) Check puncta on the medial end of each upper & lower lid for Inflammation, Regurgitation of fluid, Blockage.
iii) Press on each side of the nose for evidence of blockage or inflammation in the nasolacrimal sac.
6. Anterior Chamber: Shine the light across the cornea tangentially to look for the highlight and shadow of any corneal opacity and
for the crescentic shadow of a shallower than normal anterior chamber.
a) Sclera:
i) Episcleritis: Is a relatively asymptomatic acute onset redness in one or both eyes. Typically, you'll observe a sectoral
injection of the episcleral and overlying conjunctival vessels, although the redness may be diffuse throughout these

21
 tissues. Occasionally, there may be a translucent white nodule centrally within the inflamed area (nodular episcleritis).
While some patients complain of mild pain or tenderness to the affected region, particularly upon manipulation, often
there is no associated discomfort. The cornea remains clear in this condition, although long-standing or recurrent
episcleritis may lead to dellen formation. There is no associated anterior chamber reaction.
ii) Jaundice- look for yellow. Tell patient to look down WHILE holding upper eyelid
b) Cornea: Ensure it is clear, Without lesions, opacities, & abnormality. VIEWED FROM THE SIDE WITH PENLIGHT.
Looking for a bulge
i) Arcus senilis: Grayish or whitish arc or circle visible around the peripheral part of the cornea in older adults. Arcus
senilis is caused by lipid deposits in the deep layer of the peripheral cornea and not necessarily associated with high
blood cholesterol.
(1) Should always indicate to the physician the need to explore the possibility of alcoholism, particularly when it is
detected in males under the age of 60.

(2)
ii) Keratitis: Infection or inflammation of the cornea (the centre portion of the eye that surrounds the pupil) & is usually
accompanied by eye pain, photophobia, foreign body sensation, tears, & blurred vision.
c) Iris:
i) Inspect: For Color and Uniformity, Nodules, Vascularity of the surface of the iris, Look for any coloboma, & Any
corneal arcus [if occurs in elderly individuals known as arcus senilis & is pictured above].
ii) Iritis: Inflammation predominantly located in iris. More correctly classified as anterior uveitis. Ciliary body can also be
inflamed and is called iridocyclitis.

(1)
iii) Increased iris vascularity  Indicates diabetes
d) Pupil: Check the shape, size, symmetry and regularity of each pupil.
i) Pupillary reflexes: With one hand blocking transmission of light to the opposite eye shine the penlight into each pupil,
coming in from the side, and assess the direct and consensual reflex on each eye.
ii) Reflection: Check for any light being reflected in the pupil from a cataract or (in children especially) from a
retinoblastoma.
iii) Accommodation reflex: Check the pupillary response on each eye in the accommodation reflex.
iv) Adie’s pupil: Widely dilated, Light reflex absent, Near reaction present
v) Argyll-Robertson Pupil: Irregular pupils bilaterally, React to near reaction but not light  e.g. syphilis & diabetes
vi) Horner’s syndrome: Partial ptosis, Constricted pupil, Anyhdrosis
vii) Bilateral dilated pupil  Brain damage, Anti-cholinergic poisoning
viii) Small fixed pupils  Pontine hemorrhage, Opiate poisoning
e) Anterior chamber:
i) Anatomy: Circulates aqueous humor, Contains ciliary body through pupil to iridocorneal angle, Drained by canal of
Schlemm
ii) Hypaema: Hemorrhage in anterior chamber of the eye
iii) Hypopyon: Accumulation of pus in anterior chamber of the eye

22
 iv) Technique:
v) Narrow angle  Indicates glaucoma [increased fluid in anterior chamber due it increased aqueous humor production or
impaired drainage]
f) Lens:
i) Cataracts: Opacity that develops in the crystalline lens of the eye or in its envelope

ii) Aphakia: Absence of a lense

7. Extraocular muscles: Check the extraocular eye movements using the four tests.

a) Movements:
b) Corneal reflection: Already done
c) Convergence: Of the accommodation reflex.
d) H test: Starting in midgaze and moving in the horizontal plane until one or two flicks of nystagmus are observed, then the
upward and downward movements of the eye at this lateral position. Cross to the opposite lateral plane and assess the vertical
movements once more. Watch during all of this that both eyes remain conjugate throughout.
e) Cover/uncover test: Ask the patient to fix his gaze on an object in the middle distance. Cover one eye. After 20 seconds take
the cover away and watch to see if the covered eye has maintained its position. Check the opposite eye the same way.
f) Lateral deviation, Ptosis, Dilated pupil  Occulomotor nerve [CN IV] palsy
g) Inability to look down  Trochlear nerve [CN IV] palsy
h) Medial deviation of the eyeball  Abducens nerve [CN VI] palsy
i) Strabismus: Condition in which a person can’t align both eyes simultaneously
j) Exotropia: Divergent eyeballs
k) Esotropia: Convergent eyeballs
l) Squint: Either paralytic or non-paralytic
m) Nystagmus
i) Horizontal  e.g. Cerebellar lesion, Brain stem lesion, Drugs [e.g. ethanol & phenytoin]
ii) Vertical  e.g. From inner ear, Vestibular disease, Brainstem disease, PCP
8. Visual acuity: Position your patient 20 feet from the Snellen’s chart. Cover each eye in turn. Get the patient to read the lowest
line on the chart possible. If the patient reads the line correctly, ask them to try the next line. When the lowest line the patient can
read is reached, the line is counted if the patient accurately identifies greater than 50% of the letters. Check the vision finally with
both eyes uncovered.
a) Myopia: Near- or short-sightedness, is a refractive defect of the eye in which collimated light produces image focus in front
of the retina when accommodation is relaxed. See nearby objects clearly but distant objects appear blurred.
b) Hyperopia [hypermetropia]: Farsightedness or longsightedness, is a defect of vision caused by an imperfection in the eye
(often when the eyeball is too short or when the lens cannot become round enough), causing inability to focus on near

23
 objects, and in extreme cases causing a sufferer to be unable to focus on objects at any distance. People with hyperopia can
experience blurred vision, asthenopia, accommodative dysfunction, binocular dysfunction, amblyopia, and strabismus.
c) Presbyopia: Eye exhibits a progressively diminished ability to focus on near objects with age.
d) Astigmatism: When an optical system has different foci for rays that propagate in two perpendicular planes. If an optical
system with astigmatism is used to form an image of a cross, the vertical and horizontal lines will be in sharp focus at two
different distances.
9. Visual field: Sit facing the patient at the same level two feet away.
a) Testing Temporal field:
i) Assess the temporal field of both eyes by asking the patient to indicate when he/she sees your moving fingers as you
move them forward from behind the lateral margins of the orbits in the horizontal plane and the upper and lower lateral
quadrants.
ii) If one eye sees your fingers at a significant distance before the other, assess each eye separately to ensure that there is no
cortical extinction in the weaker eye.
b) Testing Nasal field: Then cover one of your eyes and ask the patient to cover their opposite eye (ie the patient’s right eye and
the examiner’s left eye). Assess when the patient sees you fingers in both vertical planes and in the horizontal and upper and
lower nasal quadrants. This test assumes that the examiner’s field of vision is normal.
c) Defects:

d)
10. Retinal Examination: Set the ophthalmoscope to the largest plain white circle of light

a) Structure:
24
b) Normal retina: Disk color is yellowish/orange/white, Disc vessels are tine, Disk margins are sharp
c) Method:
i) Set the lens to the examiner’s acuity correction
ii) Place the instrument in front of one eye with the cushioned bar firmly against the upper eyebrow.
iii) Hold it with the ipsilateral hand and have the index finger extended so that it is able to control and change the lens easily.
iv) Start about three feet from the patient.
v) Examine the same eye as you are using. (The patient’s right eye is examined by the examiner’s right eye with the
instrument held in the examiner’s right hand).
vi) Observe the RED REFLEX in the pupil of the patient’s eye [if absent then cataract, corneal scarring, retinoblastoma]
vii) At an angle of approximately 15 degrees from the sagittal plane approach the patient’s eye until a blood vessel is seen.
viii) Focus until this vessel is clear.
ix) Follow it to the optic disc.
x) Observe the DISC [outline, color, & look for white/pigmented crescent rings] and CUP [cup/disk ratio].
xi) Follow the vessels to each of the four quadrants of the retina.
xii) Observe the ARTERIES, VEINS and retinal background.
Arterioles Veins
Color Light red Dark red
Size Smaller Larger
Light reflex Bright Absent
xiii) When this is completed, ask the patient look into the light.
xiv) Observe the macula and fovea.
d) Clinical correlations:
Drusen: Look like specks of yellowish material under the Colobama: Is a hole in one of the structures of the eye, such as
retina. They are deposits of extracellular material that the lens, eyelid, iris, retina, choroid or optic disc. Present from
accumulate between the retinal pigment epithelium (RPE). birth. A coloboma can occur in one or both eyes.
A few small drusen normally form in the human eye,
usually after age 40.

Glaucoma: Involving loss of retinal ganglion cells in a Hypertensive retinopathy:

characteristic pattern of optic neuropathy. Although raised 1st stage: Copper wiring, Silver wiring
intraocular pressure is a significant risk factor for 2nd stage: Areterioveinous nicking
developing glaucoma, there is no set threshold for 3rd stage: Hemorrhages [flame shaped], Exudates that are hard
intraocular pressure that causes glaucoma. or soft [cotton wool]
4th stage: Papilledema & Hemorrhages [flame shaped]
Roth's spots: Retinal
hemorrhages w/ white or pale
centers of coagulated fibrin.
 Bacterial endocarditis

Papilledema: Disk is pink instead of white, Disc vessels Diabetic retinopathy: Hemorrhages [dot/blot], Microaneurysms,
are more visible, more numerous & curve over the borders Exudates [hard/waxy, Neovascularization
of the disk, Disk is swollen w/ blurred margins
Is a late sign of increased intracranial pressure

25
26
 Heart Examination
1. Anatomy:
Auscultation areas: Apical pulse location:

Electrical conduction system:

Surface Anatomy:
Precordium: Anterior chest that overlies the heart
Location: Heart & great vessels lie between 2nd–5th
intercostal spaces, behind the sternum & left chest

Veins of the neck:

External jugular vein: Sits on top of SCM
Internal jugular vein: Sits on below the SCM
Common carotid (artery): Lies right behind internal
jugular vein

a)

27
2. Cardiac Cycle:
a) Cardiac cylce: Jugular venous pulse:
i) S1: Closing of mitral & tricuspid valves [AV valves]
ii) S2: Closing of aortic & pulmonic valves
iii) S3: Rapid ventricular filling

3 positive waves: a, c, & v

2 negative descents: x & y
Compare JVP & Carotid: JVP Carotid A wave: Atrial contraction
Palpable No Yes X wave: Follows A wave & is interrupted by C wave
Wave shape Soft, Undulating, Multiple Single sharp wave C wave: Rise in pressure prior to right ventricular
peaks systole
V wave: Due to venous filling in systole against
Can be occluded: Yes No
closed tricuspid valve
Varies w/ position Yes No Y Descent: Early systole due to decreased right atrial
Varies w/ respiration Yes No pressure

3. Examination:
a) Measuring JVP:
i) Have patient sit at 30-45° angle
ii) Locate the highest level of JVP
iii) Locate the sternal angle
iv) Place ruler @ sternal angle
v) Have a horizontal edge at top level of internal JVP’s
vi) Read the vertical distance on ruler in cm
vii) Measured in mm of H2O
viii) normal JVP is 2-3cm of H2O
ix) Right atrium is 5cm below the sternal angle
x) CVP = JVP + 5cm
xi) Approximate 0-8cm of H2O, Be sure to report the angle
xii) Clinical correlations:
(1) Large v waves  Tricuspid regurgitation
(2) Giant/cannon a waves  Hepatojugular reflux, Complete heart block?????
(3) Absent a waves  Atrial fibrillation

28
b) Inspection: Precordial area for Apical pulse location:
i) Apical pulse: Best visible tangentially & is about 7-9cm from mid-
sternal line or medical to mid-clavicular line in the 5th intercostal space
ii) Pulsation in other cardiac areas
iii) Pulsations in the neck
iv) Pulsation in the epigastric areas
v) Scars
vi) Deformaties of sternum or thoracic wall

c) Palpation: Locate sternal angle: Searching for thrills:

i) Locate sternal angle & intercostal spaces
ii) Use ball of your hand to feel for thrills: Palpable murmurs, caused by
turbulence of blood flow. Vibrations felt is synonymous to purring of a
cat.
iii) Palpate the cardiac areas with your finger tips for pulsations
iv) Palpate for right ventricular heaves
v) Palpate for epigastric pulsations:
(1) Pulsations felt from below: Abdominal aorta aneurysm Pulsation palpation:
(2) Pulsations felt from fingertips [above]: Right ventricles

d) Percussion: Means to tap the surface to determine underlying structures. Sounds travels to the Percussion technique:
underlying tissues through chest wall and reflects back & is picked up by the examiner. Different
areas produce different sounds. Over heart & solid organs the sound is dull.
i) Technique:
(1) If right handed, place the middle finger of the LEFT hand on the surface you are going to
percuss, this is known as the pleximeter finger.
(2) Middle finger of right hand you tap with your plexor finger.
(3) Movement is at the wrist
ii) Method: Always done paralellel to the border of the organ you are percussing
(1) Left border of the heart: Start from the anterior axillary line in the 3rd, 4th, 5th, intercostal
space from anterior axillary line & look for lung resonance to dullness to obtain the left
border
(2) Right border of the heart: Start in the same spaces in the midclavicular line and stop @ the
sternum

29
4. Auscultation: Auscultate all cardiac areas Read about heart sounds in Bates pg. 160 in
a) 1st with the diaphragm  High pitched sounds pocket version.
b) 2nd with the bell  Low pitched sounds
c) Heart sounds:
i) S1: Closing of mitral & tricuspid valves [AV valves]
ii) S2: Closing of aortic & pulmonic valvescan be split physiologically in
children & young adults, accentuated by inpiration, & dissapears on exertion.
Aortic valve usually closes slightly earlier than pulmonic.
iii) S3: Rapid ventricular filling [low pitch]  Mitral [5]
(1) Can normally be heard in children & young adults
(2) In older individuals may be change in ventricular compliance
iv) S4: Atrial contraction [low pitch] Between [4] & [5] Precedes S1 & due to
pathological change in ventricular compliance or is in highly trained athletes
v) Murmurs  Due to turbulence of blood flow
(1) Between S1-S2: Systolic & high pitched
(2) Between S2-S1: Diastolic & low pitched & soft
(3) Special positions to hear murmurs:
Lateral decubitis position for MS [left- Position for AR [diastolic
sided S3 & S4 diastolic murmur] decrescendo murmur]

Mitral area [5] Erbs [3]

d) Describing murmurs:
i) Timing:
Midsystolic: Innocent, Pansystolic: MR, TR, Late systolic: MVP
Physiolgoic, AS, HCOM, PS VSD

Early diastolic: AR Mid diastolic: MS Late diastolic

ii) Shape:
Crescendo Decrescendo Crescendo/ Plateau
Decrescendo

iii) Intensity/Grade: Point of max intensity

Grade 1: Grade 2: Grade 3:
Very faint, needs Quiet, but readily heard Moderately loud
skillful listening
Grade 4=patholo Grade 5:=pathological (4-6) Grade 6:
Loud with a thrill Very load, thrill, & stethoscope Heard without
partially on chest stethoscope
iv) Pitch: High, Medium, Low
v) Quality: Blowing, harsh, musical rumbling
e) Murmur special techniques: Used to distinguish between Mitral valve prolapse
[MVP], Hypertrophic cardiomyopathy [HCOM], & Atrial stenosis [AS] murmurs.
[PR=Peripheral resistance VR=Venous return]
i) Squatting  ↓VR & ↓PR, Standing:  ↑VR & ↑PR
ii) Valsava maneuver:
(1) Patient stands & strains against strained glottis: ↓VR & ↓PR
(a) MVP: ↑MVP & earlier click, ↑murmur intensity
(b) HCOM: ↑out flow obstruction, ↑murmur intensity
(c) AS: ↓blood volume, ↓murmur intensity
(2) Patient squats & releases: ↑VR & ↑PR
(a) MVP: ↓MVP & later click, ↓murmur intensity
(b) HCOM: ↓out flow obstruction, ↓murmur intensity
(c) AS: ↑blood volume, ↑murmur intensity
f) Questions to ask about symptoms: When did it start? Location? Does it radiate?
Duration? Character of symptom? Relieving factors? Aggravating factors?
Associated symptoms?
30
5. Signs & Symptoms:
a) Questions to ask about symptoms: When did it start? Location? Does it radiate? Duration? Character of symptom? Relieving
factors? Aggravating factors? Associated symptoms?
b) Chest pain can be due to:
i) Angina pectoris: Intermittent chest pair or discomfort due to transient, reversible myocardial ischemia, not quite infarction.
Usually lasts about 5-10 minutes. 3 types
Name Etiology/Pathogenesis Presentation Relieving factors
Typical Most common form. Critical Crushing or squeezing substernal pain that may radiate down Rest &
[stable] stenosis [reduction of coronary left arm Vasodilators
artery to fixed stenosis] Associated w/ increased demand- physical activity, emotional
excitement
Prinzmetal Cause & mechanism not clear Occurs @ rest & awakens patient from sleep [not associated Vasodilators
[variant] [may be due to coronary artery w/ physical activity]
spasm] Associated w/ ST segment elevation & indicative of
transmural ischemia
Unstable Disruption of plaque w/ Harbinger of subsequent MI  Pre-infraction angina Vasodilators but
[crescendo] superimposed thrombosis & Pain that occurs w/ progressively increasing frequency & is NOT rest
vasospasm [not complete precipitated with progressively less effort. Often occurs at rest,
occlusion YET] & tends to be more prolonged in duration. Often accompanied
by nausea & diaphoresis.
ii) Pericarditis: Soreness behind the sternum, Aggravated w/ deep inspiration & movement.
iii) Shingles:
iv) Gastro esophageal reflux:
v) Dissecting aortic aneurysm: Severe persistent pain w/ tearing sensation between scapula
vi) Musculoskeletal pain: Pain from chest wall
vii) Pleuritic pain: Pain from parietal pleural layers
c) Dyspnea types & causes:
i) Shortness of breath [SOB]-on exertion
ii) Orthopenia: SOB on lying flat [usually requires 2 or more pillows to sleep]
iii) Paroxysmal nocturnal dyspnea [PND]: Accompanied by white & frothy sputum
iv) Anxiety disorders: Dyspnea not related to exertion, sighing excessively
v) Lung disease:
d) Palpitation: Abnormal awareness of heart beat & can be caused by  Thyrotoxosis [hyperthyroidism], Caffeine products,
Sympthmimetic drugs, Cardiac arrythmias [MVP, Extrasystoles, PSVT]
e) Syncope: Sudden loss of consciousness due to reduced blood supply to the brain  Can be caused by cardiac arrhythmias,
vasovagal response, postural hypotension, mictruation syncope, vertebro-basilar synocope
f) Peripheral signs of CVS dysfunction:
i) Pulse: Described in vital signs
ii) Clubbing:
(1) Hypertrophy of angle between nail base & finger: Angle between nail-base &
finger is obliterated [normally less than 180 degrees]
(2) Beak shaped/ Drum-stick appearance
(3) Tissues at the base of the nailbed are thickened
(4) Cardiac causes: Bacterial endocarditis, Cyanotic congenital heart diseases,
(5) Pulmonary causes: Lung cancer, Empyma, Cystic fibrosis, Fibrosing
alveolitis
(6) GI causes: Inflammatory bowel diseases [Chron’s disease, Ulcerative colitis],
Cirrhosis
(7) Congenital:
(8) Idiopathic:
iii) Signs of infective endocarditis:
Splinter Janeway lesions: Painless Osler’s nodes: Painful red Roth's spots: Retinal Conjuctival/Scleric
hemorrhages: erythmatous hemorrhagic nodes in pulp of fingers, hemorrhages w/ white or hemorrhages:
macular or nodular lesions palms, toes, & soles of pale centers of coagulated
on the palms of hands feet fibrin

31
iv) Cyanosis: 2 Types, Peripheral & Central
Peripheral cyanosis  Associated with Cold/Congestive Central cyanosis [Occurs when 5gms Hb is desaturated]
heart failure/Peripheral Vascular Disease [PVD]/Raynaud’s  Associated with severe hypoxemia & right to left
phenomenon shunt

v) Hypertensive retinopathy: Conjuctival/Scleric

(1) 1st stage: Copper wiring, Silver wiring hemorrhages  Can indicate
(2) 2nd stage: Areterioveinous nicking hypertension
(3) 3rd stage: Hemorrhages [flame shaped], Exudates
that are hard or soft [cotton wool]
(4) 4th stage: Papilledema & Hemorrhages [flame
shaped]

vi) Malar flushing  May indicate mitral stenosis [MS]?????

vii) Systemic Edema  RHF, Renal failure, Unregulated secretion of ADH
(1) Examine: Bony prominences on dorsum of foot, behind medial malleolus, & on anterior tibia for pitting edema

(2) Classification:
viii) Pulmonary edema  Heard as rales during auscultation & indicate  LHF, Pneumonia, etc

32
6. Diseases:
a) Mitral stenosis:
i) Etiology: Rheumatic fever, Calcification
ii) Results in  Increased back pressure 
(1) Left atrial hypertrophy
(2) Pulmonary congestion
(3) Atrial fibrillation
(4) Right ventricular failure

b) Mitral regurgitation:
i) Etiology: Mitral valve prolapse [MVP], Rheumatic
fever, Ruptured chordae tendineae, Injury to papillary
muscle,
ii) Results in  Increased back pressure 
(1) Left ventricular enlargement
(2) Left atrial hypertrophy & dilation
(3) Atrial fibrillation
(4) Pulmonary edema & HTN
(5) Right ventricular failure

c) Aortic stenosis:
i) Etiology: Progressive degeneration & calcification of
the valve
ii) Results in 
(1) Left ventricular hypertrophy
(2) Angina or infarction
(3) Arrhythmias  Can result LVF & sudden death

d) Aortic regurgitation:
i) Etiology: Rheumatic fever, Syphilis/endocarditis,
Dissecting aortic aneurysm
ii) Results in 
(1) Left ventricular hypertrophy/Left atrial
enlargement
(2) Angina/CHF
(3) Endocarditis
iii) Signs:
(1) Capillary pulsations in the nail bed [Quincke’s
pulse]
(2) Femoral bruit [pistol shot]  Durozier’s sign
(3) Head nodding with the pulse  de Musset’s sign
(4) Mid diastolic murmur
(5) Austin Flint murmur

33
e) Atrial septal defect: Left to right shunt, it might switch
later forming Eisenmenger’s complex
i) Etiology: Usually congenital
ii) Results in:
(1) Right ventricular enlargement
(2) Pulmonary HTN
iii) Signs:
(1) Wide, fixed splitting
(2) Pulmonary flow murmur
(3) EKG may show Right Bundle Branch Block
[RBBB]

f) Ventricular septal defect: Left to right shunt, it might

switch later forming Eisenmenger’s complex
i) Etiology: Usually congenital small defect, If large
associated with growth retardation & CHF
ii) Results in:
(1) Right ventricular enlargement
(2) Pulmonary HTN
iii) Signs:
(1) Loud pansystolic murmur  Maladie de Roger
(2) Forceful apex beat with a thrill
(3) Mitral diastolic flow murmur
g) Patent ductus arteriosus: Left to right shunt

h) Tetrology of fallot: Right to left shunt

i) Results in:
(1) Cyanosis immediately or soon after birth
(2) Increased feeding & crying
(3) Patient becomes apneic or unconscious
(4) Growth retardation
(5) Clubbing
(6) Polycythemia

34
i) Eisenmenger’s syndrome: Right to left shunt that is due to
shunt reversal in large ventricular or atrial septal defects
i) Results in:
(1) Right ventricular hypertrophy
(2) Pulmonary HTN
ii) Signs:
(1) Clubbing
(2) Central cyanosis
(3) EKG will reveal right ventricular hypertrophy

j) Hypertrophic cardiomyopathy [HCOM]: Obstructive

i) Etiology: 50% of cases autosomal dominant mutation
ii) Results in:
(1) Stiff ventricles impede diastolic filling
(2) Septal hypertrophy causing LV out flow tract
obstruction
iii) Signs:
(1) Angina on exertion
(2) Dyspnea on effort
(3) Syncope
(4) Sudden death in young adults

k) Coarctation of the aorta:

i) Etiology: Congenital disorder
(1) Usual site: After the origin of subclavian artery
on the left
(2) Often accompanies bicuspid aortic valve
ii) Results in:
(1) Radio-femoral delay
(2) Chest X-ray shows rib notching from dilated
intercostal arteries
l) Congestive heart failure:
i) Etiology: Multiple causes
(1) Pressure overload: LVH & then LVE
(2) Volume overload: LVH & LVE occur together
(3) Most common cause of RHF is LHF
ii) LHF results in:
(1) Hypotension  BP could be normal due to
increased peripheral resistance
(2) Pulmonary edema  SOB & Rales @ base of the
lung
iii) RHF results in:
(1) ↑JVP, Pitting edema, ↑Liver congestion, ↓BP

m) Cardiac tamponade: Accumulation of fluid in pericardial space

i) Slow effusion results in:
(1) Right sided heart failure
(2) Severe pitting edema & ascites
(3) Pulsus paradoxus NOT as prominent
ii) Rapid effusion results in: MEDICAL emergency  Patient is very ill
(1) ↑Peripheral resistance, Hypotensive, Chest x-ray shows enlarged heart
(2) Pulsus paradoxus

35
n) Heart block: Sometimes the signal from the heart's upper to lower chambers is impaired or doesn't transmit. This is "heart
block" or "AV block." This does not mean that the blood flow or blood vessels are blocked. Heart block is classified
according to the level of impairment — first-degree heart block, second-degree heart block or third-degree (complete) heart
block.
i) First-degree heart block:
(1) First-degree heart block, or first-degree AV block, is when the electrical impulse moves through the AV node more
slowly than normal. The time it takes for the impulse to get from the atria to the ventricles (the PR interval) should
be less than about 0.2 seconds.
(2) If it takes longer than this, it's called first-degree heart block.
(3) Heart rate and rhythm are normal, and there may be nothing wrong with the heart.
(4) Certain heart medicines such as digitalis (DIJ'ih-TAL'is) can slow conduction of the impulse from the atria to the
ventricles and cause first-degree AV block. Also, well-trained athletes may have it.
(5) Generally, no treatment is necessary for first-degree heart block.
ii) Second-degree heart block: In this condition, some signals from the atria don't reach the ventricles. This causes "dropped
beats." On an ECG, the P wave isn't followed by the QRS wave, because the ventricles weren't activated. There are two
types:
(1) Type I second-degree heart block, or Mobitz Type I, or Wenckebach's AV block: Electrical impulses are delayed
more and more with each heartbeat until a beat is skipped. This condition is not too serious but sometimes causes
dizziness and/or other symptoms.
(2) Type II second-degree heart block, or Mobitz Type II: This is less common than Type I but generally more serious.
Because electrical impulses can't reach the ventricles, an abnormally slow heartbeat may result. In some cases a
pacemaker is needed.
iii) Third-degree heart block:
(1) Complete heart block (complete AV block) means that the heart's electrical signal doesn't pass from the upper to the
lower chambers. When this occurs, an independent pacemaker in the lower chambers takes over. The ventricles can
contract and pump blood, but at a slower rate than that of the atrial pacemaker.
(2) These impulses are called functional or ventricular scope beats. They're usually very slow and can't generate the
signals needed to maintain full functioning of the heart muscle. On the ECG, there's no normal relationship between
the P and the QRS waves.
(3) Complete heart block is most often caused in adults by heart disease or as a side effect of drug toxicity. Heart block
also can be present at — or even before — birth. (This is called congenital heart block.) It also may result from an
injury to the electrical conduction system during heart surgery. Complete heart block may be a medical emergency
with potentially severe symptoms and a serious risk of cardiac arrest (sudden cardiac death). If a pacemaker can't be
implanted immediately, a temporary pacemaker might be used to keep the heart pumping until surgery can be
performed.

36
 Examination of the Lymphatic System
1. Anatomy: Cervical nodes described in section on head & neck

2. Lymphatic system examination: Inspection of the upper and the lower extremities observing any obvious swellings.
Axillary lymph nodes: Epitrochlear node palpation: Palpate the area which is proximal and
Inspection: Inspect the axilla, you may see swelling slightly anterior to the medial epicondyle.
Patient position: Usually patient is seated or reclined for
this examination. Examiner tends to raise the patient’s
arm, and using the left hand for the patients right axilla,
(and vice versa) the examiner passes their extended
fingers high into the patient’s axilla. The patient’s arm is
now brought to rest on the examiners forearm. Now the
examiner should palpate for the following. Every effort
should be made to feel for nodes in each of in each of the
nodes shown in the image below.

1. Central (push up 2. Lateral (humoral) 3. Anterior

deep into axilla) (Pectoral)
4. Infraclavicular 5. Posterior Medial
(subclavian) (Subscapular)

37
 Inguinal lymph nodes: Two groups of inguinal lymph nodes. The
horizontal group lies below the inguinal ligament and the vertical group
lie along the upper portion of the saphenous vein.
Patient position: Have the patient reclined on the couch for this
assessment. You will need to expose the groin area.
Palpation: Now feel around the inguinal ligament area and along the
femoral vessel area. Note that small nodes can be commonly detected in
otherwise normal patients.

3. Describing lymph nodes: Size, Shape, Location, Consistency, Mobility, Matted or not
i) Normal: Generally not palpable Small, Mobile, Firm Non-tender, Discrete
ii) Inflamed: Enlarged Soft to firm, Tender, Discrete, Red on Surface [erythmatous]
iii) Cancerous: Enlarged, HARD, Non-tender, Matted, Adherent to surrounding structures [Non-motile]
4. Generalized lymphadenopathy:
a) Causes: Leukemias, Lymphonas, Infections [viral, bacterial & protozoal], Connective tissue diseases, Drugs
5. Lymphadema: Occurs when there is a problem with the lymphatic drainage and therefore there is an accumulation of lymphatic
fluid in the tissues. Lymphedema is a non-pitting edema. There are 2 Types.
a) Primary lymphedema: Occurs when there is an inherited or congenital problem with the lymphatic system. 3 sub-types.
i) Congenital: Generally presents @ birth. An example is Milroy’s disease
ii) Lymphademe tardai: Generally presents in adulthood [after 35]. An example is Meige disease.
iii) Lymphadema praecox: Presents in early adulthood [before 35] & is not clinically evident @ birth.
b) Secondary lymphedema: Occurs when there is damage to the lymphatic system [e.g. radiation therapy, surgery, parasitic
infection e.g. philariasis, surgical lymph node removal, malignant tumor invasion].

38
 Peripheral Vascular System Examination
1. Anatomy:

2. Equipment: Tourniquet, Measuring tape, Watch with second hand

3. History: Smokers, Patients w/ family history or arterial disease, Diabetics, Patients w/ hypertension, Patients with
hyperlipidemia, Obese patients, Patients with atherosclerosis  At risk for developing peripheral vascular disease
4. General for techniques for both limbs: Be sure the limb being inspected is adequately exposed & be sure to examine soles of
feet & palms of hands. Be sure to compare limbs.
a) Inspection: Generally only lower limbs are checked for signs of venous disease b/c it is rare in upper limbs.
i) Size: Assess for muscle atrophy [arterial insufficiency] or edema [venous disease]
ii) Symmetry:
iii) Shape:
iv) Swelling: Assess for pitting edema [venous disease] on dorsum of foot posterior to medial malleolus & anterior to the
tibia
v) Scars:
vi) Skin moisture: Dryness, Atrophy, Shiny appearance
vii) Skin color: Note if pale [arterial insufficiency], or is cyanotic or has brown pigmentation [venous disease]
viii) Stasis dermatitis: Stasis dermatitis is skin irritation and breakdown due to the fluid accumulating under the skin. Can be
due to venous insufficiency (vein valve malfunction), heart failure, and other conditions that cause swelling, usually in
the legs, but sometimes in other areas as well.
ix) Hair: Loss [may indicate arterial insufficiency]
x) Nails: Thickened [may indicate arterial insufficiency]
xi) Pigmentation: Shiny skin [may indicate arterial insufficiency]
xii) Ulcers: Particularly around medial malleolus [arterial insufficiency]
xiii) Veins: Pattern, Varicosities [large dilated veins indicative if venous disease]
xiv) Gangrene: [arterial insufficiency]
b) Assess the 5 P’s of arterial insufficiency:
i) Pain
ii) Paresthesias
iii) Pallor
iv) Pulselessness
v) Perishingly cold

39
 vi) Other signs of arterial insufficiency: Intermittent claudication [pain upon walking that is relieved by rest], Rest pain,
Ulcers, Gangrene, Loss of hair, Shiny skin, Thickened nails
c) Palpation: Be sure to compare limbs
i) Temperature: Done bilaterally w/ backs of your hands [more sensitive to temperature differences]  Warm indicates
venous disease & cold indicates arterial insufficiency
ii) Tenderness:
iii) Pain:
iv) Swelling:
v) Cords:
vi) Edema:
vii) Pulses:
(1) Pulses described in more detail in vital signs
(2) Grading:
Grade 0 Absent
Grade 1+ Palpable but diminished
Grade 2+ Normal, palpable and brisk
Grade 3+ Increased
Grade 4+ Very increased, bounding
d) Auscultation: Any artery in which aneurysm is suspected.
5. Upper limb: Be sure to expose both upper limbs for comparison
a) Pulse palpation: Brachial [underneath biceps brachia muscle on medial side], Radial, & Ulnar arteries
b) Allens test: Testing for arterial insufficiency. Generally done before ABG [arterial blood gas] tests b/c either ulnar or radial
arteries are punctured. If there are signs of arterial insufficiency in either artery then that arm can’t be used.
i) Palpate the radial and the ulnar pulses
ii) Ask the patient to make a fist and then occlude the two arteries with pressure
iii) Have the patient open his/her hand (the hand should be pale) and release one of the vessels.
iv) Watch for a flush of color returning to the hand (within 3-5 seconds).
v) Repeat this test releasing the other artery.
6. Lower limb: Be sure to compare limbs
a) Inspection:
i) Ulcers/Gangrene: Particularly around medial malleolus & on soles of feet [arterial insufficiency]
ii) Veins: Pattern, Varicosities [large dilated veins indicative if venous disease]
iii) Swelling: Assess for pitting edema [venous disease] on dorsum of foot posterior to medial malleolus & anterior to the
tibia
iv) Stasis dermatitis: Stasis dermatitis is skin irritation and breakdown due to the fluid accumulating under the skin. Can be
due to venous disease (vein valve malfunction), heart failure, and other conditions that cause swelling, usually in the
legs, but sometimes in other areas as well.
v) Pigmentation: Hemosiderin [brown pigment] deposition indicates venous disease
b) Measurement if swelling is evident:
i) Measure circumference of both lower limbs 8-9cm below tibial tuberosity
ii) If swelling equal  Suspect RHF
iii) If swelling unequal  Suspect venous disease
c) Pulse palpation:
i) Femoral: Below the inguinal ligament and midway between the ASIS and the pubic tubercle.
ii) Popliteal: In the popliteal fossa
iii) Dorsalis pedis: Lateral to the long extensor tendon of the great toe
iv) Posterior tibial arteries: Posterior to the medial malleolus
d) Systemic Edema  RHF, Renal failure, Unregulated secretion of ADH
i) Examine: Bony prominences on dorsum of foot, behind medial malleolus, & on anterior tibia for pitting edema

ii) Classification:
e) Auscultation: Auscultation of the femoral pulses for bruits should be included in the examination of the arterial system.
f) Bueger’s test: Testing for arterial insufficiency
i) Have the patient lie on the bed
40
 ii) Raise both the legs to approximately 60°
iii) Have the patient wiggle his/her toes and maintain in this position for 1 minute.
iv) At this point the limbs should be pale
v) Have the patient then sit up and swing his/her legs over the side of the bed.
vi) Observe the feet: Looking for color returning and the vessels filling. The color should return within 10 seconds and the
veins should fill within 15 seconds.
g) Deep vein thrombosis:
i) Risk factors: Risk factors for deep vein thrombosis: Immobilization, Surgery, Pregnancy, Obesity, Smoking, Oral
contraceptives, Fractures, Hypercoagulability, Malignancies, Economy class syndrome
ii) Signs: Pain on palpation & Swelling
iii) Pratt’s test: Involves applying gentle pressure to the calf. A positive test is pain during the application of pressure.
iv) Homan’s test: Involves dorsiflexion of the foot [tilt foot up]. A positive test is pain during dorsiflexion of the foot.
h) Varicose vein assessment:
i) Manual compression test:
(1) Inspect the lower extremities finding a varicosity & attempt to map out the course of the varicose vein.
(2) Place both hands on the vein approximately 10 cm apart & trap a column of blood between fingers of your two
hands.
(3) While continuing to compress the vessel first tap with the lower hand feeling for the transmission of a wave to the
upper hand, this ensures that both hands are placed on the same vessel.
(4) Next tap with the upper hand feeling for a wave transmission to the lower hand. Remember that the valves in the
veins are unidirectional (blood should only flow from the lower extremity upwards towards the heart).
(5) If you are able to feel the transmission of the wave from the upper hand to the lower hand this verifies that the
superficial valves of the vein are incompetent.
ii) Trandelenberg’s test:
(1) Have the patient lie on the bed.
(2) Raise one leg to 90 degrees and have the patient wiggle his/her toes (emptying the vessels of the extremity).
(3) Have the patient remain like this for approximately 60 seconds.
(4) Tie the tourniquet around the upper thigh (tight enough to occlude the superficial vessels but not the deep vessels of
the leg).
(5) Have the patient stand up & observe the leg for venous filling.
(6) If you see immediate venous filling then there is incompetence of the valves of the communicating vessels
(remember that the superficial vessel is still occluded by the tourniquet).
(7) Observe the leg for 20 seconds and then release the tourniquet and observe again.
(8) Rapid filling of the vessel at this point indicates that there is incompetence of the valves of the superficial vessel.
7. Clinical Correlations:
a) Top 5 Locations of Severe Atherosclerosis in order of frequency:
i) Abdominal aorta
ii) Proximal coronary artery
iii) Popliteal artery & Thoracic aorta
iv) Internal carotid artery
v) Circle of Willis
b) Aneurysms:
i) Aneurysms are abnormal dilatations of the arteries and may be palpable as an increased artery diameter
ii) Common locations: Ascending aorta, Abdominal aorta, Femoral artery, Popliteal artery, Intracerebral arteries

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