HISTORY TAKING - FINAL - Sumanyu258@gmail - Com - 01092014 PDF

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FUNDAMENTALS OF HISTORY TAKING & CLINICAL EXAMINATION

MEDICINE HISTORY TAKING YOU THINK OF AFTER LISTENING TO THE CHIEF
COMPLAINTS) EVEN IF THESE SYMPTOMS ARE NOT
COMPLAINED BY THE PATIENT.
A.INTRODUCTION g.LEADING QUESTIONS are asked at this stage. Leading
ouestions mean questions whose answers are to be
1.NAME
given either in Yes or in No OR questions which yield
2.AGE only one answer. For example, if a pt is asked like this-
3.RELIGION “Does not the pain move to the inferior angle of the
4.SEX scapula?” Obviously, the pt will answer Yes or No. So
5.FROM (Locality) the questions should be put in the way so that it leaves
6.OCCUPATION the pt with free choice of answers. For example, the
above questions should be-“Does the pain ever move? If
TYPICAL DESCRIPTION: Ramesh Das, 52 yr Hindu male the pt says Yes, then ask-“Where does it go? So the
from Cuttack, a farmer by occupation, presented to this questions should not necessarily be leading, but to help
hospital with chief complaints of (blood vomiting since 1 the pt to narrate the different aspects of his symptoms
day) to arrive at a diagnosis.
B.CHIEF COMPLAINTS WITH CARDIO VASCULAR SYSTEM (CVS)

DURATION 1.CHEST PAIN
>Chief complaints are noted in CHRONOLOGICAL ORDER 1.Duration

along with the duration of each complaint, 2.Onset-Severe pain from the beginning/ mild pain to
start with which then increased in severity
recorded in pt’s words i.e in the exact words in which pt
describes his complaints, but not in medicine words, 3.Progress-Stationary/ Improving/ Progressing-
Rapidly/Slowly
e.g. write scanty urination, but not oliguria. No LEADING
QUESTIONS are asked at this stage.
4.Time of appearance-Early morning/Early night
5.Episodes
>What are your complaints? Or what brings you here? &
6.Site
How long have you been suffering from each of these
7.Type
complaints?
8.Radiation
>The disease is present for this much of period, then 9.Lasting
why do you come now? 10. Aggravating Factors
11. Relieving Factors
>CHRONOLOGICAL ORDER-It means you have to 12. Associated night sweats
mention first the symptom which appeared first & then
the subsequent symptoms which appeared in succession 2.PALPITATION
of time i.e you have to mention the symptoms
appearing in succession. For example, if a person has 1.Duration
cough since 2 days, fever since 5 days & chest pain 2.Onset-Severe from the beginning/ mild to start with
since 15 days, then you have to tell the chief complains which then increased in severity
in the following way-The pt has chest pain since 15 3.Progress-Stationary/ Improving/ Progressing-
days, fever since 5 days & cough since 2 days. Never Rapidly/Slowly
tell- The pt has chest pain for 15 days, fever for 5 days 4.Rate-Fast/Slow
& cough for 2 days. That means you have to use the 5.Irregular/Regular
word “since” instead of “for”. 6.Relieving Factors-Rest/Drug
7.Aggravating factors-Exertion/Exercise/ Straining
C.HISTORY OF PRESENT 8.Passage of Urine after an Episode
ILLNESS 3.BREATHLESSNESS (DYSPNEA)
a.When you are apparently well or asymptomatic? 1.Duration

b.How was the onset of illness? Or how did the trouble 2.Onset-Severe from the beginning/ mild to start with
start? which then increased in severity
c.In what chronological order the symptoms appeared? 3.Time of appearance-Early morning/ Early night
d.How have the symptoms progressed or modified 4.Progress-Stationary/ Improving/ Progressing-
during the course of illness? Rapidly/ Slowly
e.Any treatment & its result.The answers are recorded 5.Paroxysmal/ Exertional
in pt’s language (not in scientific terms). Leading 6.How much exertion is needed
questions must not be asked. For example, ask, “Does 7.Preceeding events-Cough with expectoration
the pain ever move?” but do not ask, “Does the pain 8.Associated events-Cough/ Chest pain/ Wheeze/
move to the shoulder?” Stridor/ Shock / Fever/ Angina/ Palpitation/
f.IF SOME SYMPTOMS OF ONE SYSTEM ARE COMPLAINED Syncope/ Hypertension/ Cyanosis/ Wt loss
BY THE PATIENT, YOU THEN ASK ABOUT THE OTHER 9.Grade-I/ II/ III/ IV
RELEVANT SYMPTOMS(PERTAINING TO THE DISEASES 10. Orthopnea
WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

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11. Paroxysmal Nocturnal Dyspnea (PND) 1.Episodes
12. Seasonal variation-Present/ Absent 2.Lasting
13. Aggravating factors 3.Relieving factors
14. Relieving factors-Drugs/ Rest/ Change of smoky 4.Aggravating factors
environment/ Squatting/ Change of posture/
Expectoration 8.CONVULSION
GRADE OF BREATHLESSNESS OR DYSPNEA 1.Type-Generalised tonic-clonic/ Absense

2.Duration
GRADE CHARACTERISTICS 3.Progress
I • No limitation of physical activity 4.Episodes
• No symptoms on ordinary exertion 5.Lasting
II • Slight limitation of physical activity 6.Relieving factors
• Ordinary activity causes symptoms 7.Aggravating factors
III • Marked limitation of physical activity 8.Associated fever
• Less than ordinary activity causes 9.Any froth
symptoms 10. Whole body or one part of body
• Asymptomatic at rest 11. Tongue biting-Present/ Absent
IV • Inability to carry out any physical activity
without discomfort 9.EDEMA
• Symptomatic at rest
>There is no zero grade in dyspnea classification. 1.Duration
>In Grade-IV, the person is restricted to bed or chair. 2.Onset-Gradual(=Insiduous)/ Sudden
3.Progress
4.Site-Face/ Leg
4.COUGH
5.Pitting/ Non pitting
6.Aggravating Factors-Oliguria
1.Duration
7.Relieving Factors-Diuretics
2.Onset-Severe from the beginning/ mild to start with
which then increased in severity
10.FEVER
3.Progress-Stationary/ Improving/ Progressive-
Rapid/Slow
1.Duration
4.Expectoration
2.Onset-Gradual (=Insiduous)/ Sudden
5.Seasonal variation-Present/Absent
3.Type-
6.Diurnal variation-Present/Absent
• Continued
7.Aggravating fators-Present/Absent
• Remittent
8.Postural variation
• Intermittent-Quotidian/ Tertian/ Quatran
9.Relieving factors-Rest/ Medicine
4.Progress
5.Paroxysm-One/ Multiple
5.EXPECTORATION
6.Grade-High/ Low
7.Chills/ Rigor
1.Quantity-Scanty/Copious
8.Diurnal Variation-How long the fever stays-
2.Colour
9.H/O convulsion
3.Consistency-Mucoid/ Purulent
10. H/O drug intake
4.Foul smelling-Yes/ No
11. H/O any treatment received & its effect-
5.Blood staining-Yes/ No
6.Seasonal variation-Present/ Absent
11.RENAL SYMTOMS-Oliguria/ Nocturia
7.Postural variation-Present/ Absent
8.Aggravating Factors
12.TIREDNESS & FATIGUE (Fatigue on exertion)
9.Diurnal variation-Present/ Absent
10. Relieving Factors-Rest/ Medicine
13.MALAR FLUSH
6.HEMOPTYSIS
RESPIRATORY SYSTEM
1.Duration
2.Onset-Severe from the beginning/ mild to start with 1.COUGH
which then increased in severity
3.Progress-Stationary/ Improving/ Progressing-Rapid/ 1.Duration
Slow 2.Onset-Gradual(=Insiduous)/ Sudden
4.Episodes-1/ 2/ 3/ 4/ 3.Progress
5.Fresh blood/ Altered blood 4.Episodes
6.Aggravating factors 5.Expectoration
7.Relieving factors 6.Seasonal variation
7.Diurnal variation
7.SYNCOPAL ATTACKS 8.Postural variation

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9.Relieving factors-Rest/Medicine 7.FEVER
10. Aggravating fators 1.Duration
2.Onset
2.EXPECTORATION 3.Type-
• Continued
1.Duration • Remittent
2.Onset-Gradual(=Insiduous)/ Sudden • Intermittent-Quotidian/ Tertian/ Quatran
3.Progress 4.Progress
4.Quantity-Scanty/ Copious 5.Paroxysm-One/ Multiple
5.Amount____ml/day or____cups/day 6.Grade-High /Low
6.Colour 7.Chills/ Rigor
7.Consistency 8.Diurnal Variation-How long the fever stays-
8.Foul smelling 9.H/O convulsion
9.Blood staining 10. H/O drug intake
10. Seasonal variation-Present/ Absent 11. H/O any treatment received & its effect-
11. Postural variation-Present/ Absent
12. Aggravating Factors 8.HEAVINESS IN THE CHEST
13. Diurnal variation-Present/ Absent
14. Relieving Factors-Rest/ Medicine 1.Duration
2.Onset
3.HEMOPTYSIS 3.Progress
1.Duration 9.HOARSENESS OF VOICE

2.Onset
3.Progress 1.Duration
4.Episodes 2.Onset
5.Fresh/Altered 3.Progress
6.Aggravating factors
7.Relieving factors 10.SWELLING OF FEET
4.CHEST PAIN 1.Duration

2.Onset
1.Site-a.Localised-Retrosternal/ Lateral 3.Progress
b.Generalised
2.Onset-Sudden/ Gradual GASTROINTESTINAL SYSTEM (GIS)
3.Character- Sharp & Stabbing/ Aching/ Constipation
4.Effect of breathing & coughing-Worse/ Unrelated 1.ABDOMINAL PAIN
5.BREATHLESSNESS (DYSPNEA) • Site

• Duration
1.Duration • Onset-Gradual/ Sudden
2.Onset • Time of onset (Timing)
3.Time of appearance-Early morning/ Early night • Character (Type)
4.Progress-Stationary/ Progressive--Rapid/ Slow • Progression
5.Paroxysmal/ Exertional • Severity
6.How much exertion is needed • Frequency & Periodicity
7.Preceeding events-Cough with expectoration • Movement of pain-Shifting/ Radiation/ Referal
8.Associated events-Cough/ Chest pain/ wheeze/ • Lasting
Stridor/ Shock / Fever/ Angina/ Palpitation/ • Aggravating factors-Food/ Vomiting/ Respiration/
Syncope/ Hypertension/Cyanosis/Weight loss Posture/ Micturition/ Jolting/ Walking/ Defecation/
9.Grade-I/ II/ III/ IV Pressure
10. Orthopnea • Relieving factors-Food/ Vomiting/ Drug
11. Paroxysmal Nocturnal Dyspnea (PND) • Associated Symtoms
12. Seasonal variation-Present/Absent
13. Aggravating factors 2.ABDOMEN DISTENSION
14. Relieving factors-Drugs/ Rest/ Change of smoky
environment/ Squatting/ Change of posture/ • Duration
Expectoration • Onset
• Progress
6.WHEEZING OR STRIDOR • Relieving factors
• Aggravating factors
1.Duration
2.Onset 3.DYSPHAGIA
3.Progress
1.Duration
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2.Onset • Duration
3.Progress • Onset
4.More to-Solid/ Liquid • Frequency
5.Aggravating factors • Quantity
6.Relieving factors-Drug/ Lying down • Progress
• Colour-Bright red (fresh)/ Dark red (altered)
4.VOMITING • Mixed with Food Particle
• Aggravating Factors
• Duration • Relieving Factors
• Onset • H/O Previous dyspepsia/ Upper GI bleeding
• Progress • H/O Alcohol abuse
• Episodes • H/O Recent intake of corticosteroids/ NSAID
• Projectile • Retching preceeding hematemesis
• Nausea • Blood staining of the vomitus is apparent in first
• Timing vomitus
• Relieving factors
• Aggravating factors 9.EDEMA
VOMITUS • Site-Face/ Leg

• Amount • Duration
• Colour-Bilious/ Blood Stained • Onset
• Recent Food • Progress
• Foul Smelling • Pitting/ Non-pitting
• Aggravating Factors-Oliguria
5.DIARRHEA • Relieving Factors-Diuretic
• Duration 10.JAUNDICE
• Onset
• Progress • Duration
• Episodes • Onset
• Timing • Progress
• Relieving factors-Drug • Appetite
• Aggravating factors-Pain/ Food • Weight loss
• Urine Colour
MOTION • Stool Colour
• Amount • Skin Itching
• Colour • I.V Injection/ Tattooing/ Sexual intercourse
• Blood stained • H/O Drug abuse/ Alcohol intake
• Mucous stained • H/O Blood Transfusion
• Solid/ Watery • Associated with-Fever/ Chill & Rigor/ GI bleeding/
• Tenesmus Abdominal pain/ Altered Bowel habit
• Foul smelling • H/O travel & immunization-HBV/ HAV
• Floating in Pan • Aggravating Factors
• Relieving Factors
6.CONSTIPATION
11.MELENA [ TARRY i.e. STICKY BLACK STOOL]
• Duration
• Onset • Duration
• Progress • Onset
• Relieving factors-Drug • Frequency
• Aggravating factors-Pain/ Food • Quantity
• Progress
7.SWELLING • Associated with straining
• Loose/ Semisolid
• Duration • Associated symptoms-Vertigo/ Dizziness/ Syncopal
• Onset attack during defecation
• Progress • Aggravating Factors
• Site • Relieving Factors
• Size
• Surface 12.FEVER
• Skin over it
• Edge 1.Duration
• Extension • Onset
• Type-
8.HEMATEMESIS • Continued
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• Remittent • Onset
• Intermittent-Quotidian/ Tertian/ Quatran • Progress
• Progress • Aggravating factors
• Paroxysm-One/ Multiple • Relieving factors
• Grade-High /Low • Recent weight loss
• Chills/ Rigor • Muscle cramp
• Diurnal Variation-How long the fever stays
• H/O convulsion CENTRAL NERVOUS SYSTEM (CNS)
• H/O drug intake
• H/O any treatment received & its effect 1.HIGHER FUNCTION
13.OLIGURIA 1.Altered Sensorium

2.Speech Disturbance
• Duration • Dysarthria
• Onset • Dyphasia
• Daily Amount • Dysphonia
• Urine Colour 3.Mental Symptom–Restlessness
• Dysuria
• Hematuria 2.CRANIAL NERVES
• Aggravating Factors
• Relieving Factors 1.Sensation of smell-Normal/Abnormal
2.a.Distant vision- Able to read what is written on
14.RECTAL BLEEDING (HEMATOCHEZIA) wall.
b.Near vision-Able to read newspaper
• Duration c.Color Vision-Able to see Red/ Blue/ Green
• Onset 3.Any H/O Double Vision
• Frequency 4.Any H/O Squint
• Quantity 5.H/O Tingling/Numbness over the face/ Difficulty in
• Progress Chewing
• Colour-Bright red (fresh)/ Dark red (altered) 6.Facial Asymmetry/ Deviation of angle of mouth/
• Mixed with Food Particle Dribbling of saliva/ Difficulty in drinking Water/ Loss
• Aggravating Factors of taste sensation
• Relieving Factors 7.Vertigo/ Tinnitus/ Deafness
8.Hoarseness of voice
15.ANOREXIA 9.Nasal Twang/ Nasal intonation/ Nasal regurgitation
10. Difficulty in shrugging of shoulder
• Duration 11. Difficulty in Talking (dysar thria)/ Wasting of
• Associated Weight loss tongue muscles
12. Difficulty in swallowing (Dysphagia)
16.WEIGHT LOSS 13. Nasal regurgitation
• Duration 3.MOTOR FUNCTION

• Onset
• Progress A.WEAKNESS
• Amount
1.Distribution-A few muscles/ A limb/ Both lower
17.BONE PAIN limbs (Paraparesis)/ Both limb on one side
(Hemiparesis)
• Duration 2.Type of weakness-UMN lesion type/ LMN lesion
• Onset type
• Progress 3.Evolution of weakness-Sudden & improving/
• Tenderness Gradually worsening over days or weeks/ Evolving
• Aggravating factors over months or years
• Relieving factors
18.BLEEDING DIATHESIS I.UPPER LIMB
• Duration 1.Proximal Weakness

• Onset
• Progress Difficulty in lifting the arm above the head/ Difficulty
in Combing/ Difficulty in buttoning shirt/ Difficulty in
* Rule out MALIGNCY--16, 17 & 18 eating/ Difficulty in Placing an object on a high self/
Difficulty in lifting objects
19.FATIGUE/WEAKNESS
2.Distal Weakness
• Duration
6
Difficulty in writing/Difficulty in sewing/ Difficulty in 10. Associated migraine
buttoning the shirt
7.VOMITING
II.LOWER LIMB
1.Duration
1.Proximal Weakness 2.Onset
3.Progress
Difficulty in squatting & getting up from squatting 4.Episodes
position/ Difficulty in Climbing upstairs & going 5.Projectile
downstairs/ Difficulty in running/ Difficulty in getting 6.Nausea
up from chair/ Difficulty in stepping on to a crub 7.Timing
2.Distal Weakness ! VOMITUS

1.Episodes
Slippers slipping off the feet/ Inability to move 2.Amount
upper limbs as well as lower limbs bed ridden or 3.Colour
complete paralysis. 4.Bilious
5.Blood stain
>Ask about the ability to stand (with or without 6.Recent Food
support), walking (with or without support). 7.Foul Smelling
B.TONE-H/O of stiffness of the limbs 8.CONVULSION
C.WASTING OF MUSCLES-Proximal/ Distal 1.Duration

2.Onset
D.COORDINATION 3.Progress
4.Begin and end-Local/ Generalized
1.H/O unsteadiness of gait 5.Fall
2.H/O falling to one side [Cerebellar Ataxia] 6.Hurt himself
3.H/O Inco-ordination in dark [Sensory Ataxia] 7.Biting of tongue
4.H/O involuntary movement-Unilateral/ Bilateral 8.Defecate during fit
9.After symptoms- Sleep/ Automatism/ Headache/
E.GAIT Paralysis
10. Subsequent mental disturbance
4.SENSORY SYSTEM 11. H/O Birth complication
12. H/O Ear discharge
1.No H/O Tingling 13. H/O Recent or Remote head injury
2.No H/O Numbness 14. H/O Similar attack in infancy
3.No H/O Root Pain
4.H/O Diminished or Absence of hot and cold sensa- 9.UNCONSCIOUSNESS
tion while taking bath.
5.H/O not feeling the ground on walking or clothes on 1.Duration
body. 2.Onset
3.Progress
5.SPHINCTER DISTURBANCE 4.Age of first attack
5.Describe the attack
1.H/O Difficulty in initiation of micturition 6.Second attack
2.H/O Urgency (Difficulty in controlling micturition) 7.Shortest/ Longest interval
3.H/O Hesitancy 8.Attack occurs during sleep
4.H/O Urinary retention 9.Any Premonitory symtoms or aura
5.H/O Incontinence (Dribbling of Urine) 10. Its Character-Loss of function [Paralysis]
6.H/O Constipation/ Incontinence
7.H/O Sexual dysfunction/ Retrograde ejaculation 10.BLURRED VISION
6.HEADACHE 1.Duration
2.Onset
1.Duration 3.Progress
2.Onset
3.Progressive 11.FEVER
4.Site
5.Severity 1.Duration
6.Quality 2.Onset
7.Timing 3.Type-Continued/Remittent/Intermittent-Quotidian/
8.Aggravating factors Tertian/Quatran
9.Relieving factors 4.Progress
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5.Paroxysm-One/Multiple 3.Progress
6.Grade-High/Low 4.Aggravating factors
7.Chills/Rigor 5.Relieving factors
8.Diurnal Variation-How long the fever stays-
9.H/O convultion 3.SWELLING OF THE WHOLE BODY
10. H/O drug intake
11. H/O any treatment received & its effect- 1.Duration
2.Onset
12.PARALYSIS 3.Progress
1.Premonitory symptoms before onset 5.Relieving factors
2.How did the paralysis come on [Describe]
3.Duration 4.ALTERATION IN URINE VOLUME
4.Onset
5.Progress-Recovering/ Worsening a. SCANTY URINATION (=OLIGURIA i.e < 400
6.Site ml/24 hr)
7.Associated with vomiting
8.Symptoms of heart disease-Breathlessness/ PND/ 1.Duration
Orthopnea 2.Onset
9.Symptoms of HTN [bluring of vision] 3.Progress
10. Symptoms of diabetes mellitus
b.NO URINATION (=ANURIA i.e no urination for
13.DIZZINESS last 12 hours)
1.Duration 1.Duration
2.Onset 2.Onset
3.Progress 3.Progress
4.Type–Intermittent
5.Worsen–Change in Head Position c.INCREASED URINATION (=POLYURIA i.e > 3
6.Relieving factors litres/24 hr)
7.H/O Trauma
8.H/O Deafness 1.Duration
2.Onset
14.CEREBELLAR FUNCTION 3.Progress
1.Swaying/ Unsteadiness/ History of falling 5.RED COLOR URINE (HEMATURIA)

2.Weakness
3.Giddiness 1.Duration
2.Onset
15.SYNCOPE 3.Progress
16.AMNESIA 6.FEVER
17.SLEEP DISORDER 1.Duration

2.Onset
18.INVOLUNTARY MOVEMENTS 3.Type-
• Continued
19.APHASIA • Remittent
• Intermittent-Quotidian/ Tertian/ Quatran
20.FOCAL DEFICITS 4.Progress
5.Paroxysm-One/ Multiple
GENITOURINARY SYSTEM 6.Grade-High/ Low
7.Chills/ Rigor
1.SWELLING OF THE FACE 8.Diurnal Variation-How long the fever stays
9.H/O convulsionH/O drug intake
1.Duration 10. H/O any treatment received & its effect
2.Onset
3.Progress 7.LOIN PAIN
5.Relieving factors 1.Duration
2.Onset
2.SWELLING OF THE ABDOMEN 3.Progress
1.Duration 8.INCONTINENCE
2.Onset
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9.DISCHARGE PER URETHRA • Intermittent-Quotidian/ Tertian/ Quatran
4.Progress
LYMPHORETICULAR SYSTEM 5.Paroxysm-One/ Multiple
6.Grade-High/ Low
1.LYMPH NODE ENLARGEMENT 7.Chills/ Rigor
8.Diurnal Variation-How long the fever stays
1.Duration 9.H/O convultionH/O drug intake
2.Which group 1st affected 10. H/O any treatment received & its effect
3.Pain
4.Fever 7.RECURRENT RESPIRATORY TRACT INFECTION
5.Primary focus
6.Anorexia 1.Duration
7.Wt. loss 2.Onset
8.Pressure effects-Swelling of face & neck/ Edema & 3.Progress
Venous congestion of lower or upper limb/ Dyspnea/
Dysphagia 8.SORE THROAT
2.HEMORRHAGIC SPOTS 1.Duration

2.Onset
1.Site 3.Progress
2.Size
3.Number 9.ANOREXIA
3.BLEEDING DIATHESES 1.Duration

2.Onset
1.Epistaxis 3.Progress
2.Gum bleeding 4.Associated Weight loss
3.Menorrhagia
4.Haemarthrosis 10.WEIGHT LOSS
5.H/o prolonged bleeding
1.Duration
4.BONE PAIN 2.Onset
3.Progress
1.Duration 4.Amount
2.Onset
3.Progress 11.SWELLING IN THE ABDOMEN
5.Relieving factors 1.Duration
2.Onset
5.JAUNDICE 3.Progress
4.Site
1.Duration 5.Size
2.Onset 6.Surface
3.Progress 7.Skin over it
4.Appetite 8.Edge
5.Weight loss 9.Extension
6.Urine Colour
7.Stool Colour LOCOMOTOR SYSTEM
8.Skin Itching
9.I.V.Injection/ Tattooing/ Sexual intercourse 1.PAIN & SWELLING OF JOINT (ARTHRITIS)
10. H/O Drug Abuse/ Alcohol intake
11. H/O Blood Transfusion 1.Duration
12. Associated with-Fever/ Chills & Rigor/ GI bleeding/ 2.Onset
Abdominal pain/ Altered bowel habit 3.Progress
13. Travel&immunization history-HBV/ HAV 4.Aggravating factors
14. Aggravating Factors 5.Relieving factors
15. Relieving Factors
2.ONLY PAIN IN JOINT (ARTHRALGIA)
6.FEVER 1.Duration
2.Onset
2.Onset 4.Aggravating factors
3.Type- 5.Relieving factors
• Continued
• Remittent
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3.INVOLVEMENT OF • Addiction
1.Alcohol-a.Amount/ day- b.Duration-
-Axial skeleton/Appendicular skeleton 2.Smoking- a.Nos- b.Duration-
3.Tobacco in any form
4.INVOLVEMENT OF • Bowel
• Bladder
-Large joints/ Small joints • Allergies
5.MORNING STIFFNESS >Tell that the pt is habituated to pan & addicted to

alcohol. Do not tell pt is addicted to pan because,
• Absent habituation means, if the pt does not take the
• Present habituated things, there will be no withdrawal
1.Duration symptoms. But in addiction, if the pt discontinues
2.Onset the addicted thing, he will develop withdrawal
3.Progress symptoms.
4.Aggravating factors >Menstrual history is to be told under personal history in
5.Relieving factors
female patients.
6.MONO/ PAUCI/ POLY ARTICULAR
MENSTRUAL HISTORY
7.FLEETING/ ADITIVE
I.PRESENT CYCLE
8.ASSOCIATED H/O
a.Age of menarche
-Conjunctivitis/ Iritis/ Skin rash/ Skin nodule/ Mouth or b.LMP (First day of the last normal menstrual period)
penile ulcer/ Lymphadenopathy/ c.Duration of bleeding
Alopecia/ Dry mouth/ Previous miscarriage d.Length of the cycle (It is the interval from the first
day of one period to the onset of the next period)
e.Regularity of the cycle (Rhythm)-Regular/ Irregular
D.PAST HISTORY f.Associated clot
g.Associated pain
GENERAL II.PREVIOUS CYCLES
1.Similar attack history in the past
a.Duration of bleeding
2.No history suggestive of TB/ HTN/ Diabetes/ RHD/
b.Length of the cycle (It is the interval from the first
IHD/ Jaundice/ H/O contact with persons suffering from
TB or any contagious disease (or Pt is not a diabetic, not
c.Regularity of the cycle (Rhythm)-Regular/ Irregular
a hypertensive etc.)
d.Associated clot
3.Any Prolonged illness/Serious illness in the past
e.Associated pain
4.Immunisation history
*Mention about past menstrual history only if previous
SPECIFIC cycles are irregular. Otherwise tell-Previous cycles are
regular.
>Typical description-Menstrual period is 2-3 days in a
1.CARDIOVASCULAR SYSTEM
cycle of 28-30 days duration, regular, not associated
2.RESPIRATORY SYSTEM with pain & clot. OR Menstrual period is 2-3 days in a
3.GASTROINTESTINAL SYSTEM cycle of 28-30 days duration, regular & with average
blood flow. (Average blood flow indicates it is not
4.NERVOUS SYSTEM associated with clot)
1.MITRAL STANOSIS >Clot in menstrual flow indicates heavy bleeding. It can
2.CVA
also be determined by number of pads used.
3.HEMIPLEGIA
4.PARAPLEGIA
F.FAMILY HISTORY
E.PERSONAL HISTORY 1.H/O similar symptoms/ disease in the family
• Occupation
• Socioeconomicstatus-Poor/Average/High income G.TREATMENT HISTORY
status
• Marital status-Married/Unmarried/Widow/ Divorced/ 1.Treatment received in the home, PHC, CHC &
Separated district head quarter
• Dietary habit-
1.Regular/Irregular/Fasting/Avg.Indian diet
2.Vegetarian/Non-vegetarian
H.GENERAL EXAMINATION
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>YOU MUST STAND ON THE RT AIDE OF THE PT WHILE 1.Mild-Only the conjunctiva is yellow
EXAMINING HIM. IF YOU ARE ON THE LT SIDE OF THE PT 2.Moderate
WHEN THE EXAMINER IS ASKING YOU SOMETHING, 3.Severe-Palm or sole & skin are yellow
THEN YOU MUST COME TO THE SIDE OF THE RT SIDE OF >SEE ICTERUS ONLY IN GOOD NATURAL DAYLIGHT. Ask
THE PT & THEN DEMONSTRATE WHAT YOU ARE ASKED
the Pt. to stand in front of an open window. Do not see
FOR.
icterus inside the room & in the night.
>TELL IN THE SEQUENCE MENTIONED BELOW
>First see in the upper bulbar conjunctiva-Sclera is
examined by asking the Pt. to look down (look to his big
1.He is conscious & cooperative/ Uncooperative
toe of his feet) while you retract the two upper eyelids
upwards simultaneously by thumbs.
2.BODY BUILT
>In case of conjunctivitis or muddy conjunctiva see
-Average body built/ Chachexia mucous membrane of palate i.e both soft & hard palate
>Cachexia is characterized by combined manifestations (except in those who chew betel)-Ask the Pt. to open
mouth & then see his palate.
of anorexia, anemia plus emaciation i.e a profound state
of general ill health. >Icterus is best appreciated by inspecting the sclera
>Identification points of emaciation- under natural light.in fair-skinned individuals, yellow
color of the skin is obvious.In dark-skinned individuals,
1.H/O polyphagia, polyuria (Diabetes mellitus), depre-
the mucous membrane can demonstrate the
ssion (Anorexia nervosa), irritability (Thyrotoxicosis),
jaundice.jaundice is rarely detectable if serum bilirubin
fevers (Tuberculosis).
level is less than 2.5mg/dl, but may remain detectable
2.See the facies-For exophthalmos, thyrotoxicosis
below this level during recovery from jaundice because
3.Palpate for lymphadenopathy-Tuberculosis, Malignan-
of protein & tissue binding property of bilirubin.
cy
4.Examine for tremor-Thyrotoxicosis >Undersurface of tongue
>Soft palate
3.DECUBITUS (Posture while lying on bed) >In severe case, see the nailbed, skin, palm, soles etc.
>In carotenemia, sclera turns yellow while the skin turns
Dorsal decubitus (or of choice)/ Lateral decubitus/ lemon or orange yellow.
Propped up/ Stooping forward/ Squating/ Hemiplegic >Tell that there is mild/moderate /severe icterus.
decubitus / Lying still Do not tell that icterus is present.
HEMIPLEGIC DECUBITUS-The affected arms remains 6.CYANOSIS

flexed, adducted & semipronated while the affected
lower limb adopts extended, adducted & plantiflexed -Peripheral/ Central
attitude. As a whole,the affected side shows less >Sites to be looked for peripheral cyanosis (in good
mobility while the Pt. is in bed.Normal lower limb is
natural light)-Tip of the nose, ear lobules, outer aspect
flexed & normal upper limb is extended. You may not of lips, chin & cheek, tips of fingers & toes, palms &
tell this in examination.
soles (Tongue remains unaffected).
*TELL ONLY IN CASE OF HEMIPLEGIA.
>Sites to be looked for central cyanosis (in good
4.PALLOR natural light)-Tongue (Mainly the margins & the
undersurface), inner aspect of lips, mucous membrane
-Mild/ Moderate/ Severe of gum, soft palate & cheeks, lower palpebral
>Lower palpebral conjunctiva-Retract the lower eyelids conjunctiva, Plus the sites mentioned in the peripheral
downward & ask the Pt. to look upwards. See in both cyanosis (one must examine these sites).
eyes at a time. >In central cyanosis, both the central & peripheral areas
>Tongue-Specially the tip & the dorsum are blue while in peripheral cyanosis, only the peripheral
>Soft palate parts are blue.
>Nailbeds-Press the pulp to see the redness of nail bed >Tell-No pallor, no cyanocis etc. Never tell-Pallor
>Palm (In anemia, palmar creases are lighter colored is absent, cyanosis is absent etc.
than surrounding area of hyperextended palm), soles &
general skin surface 7.JUGULAR VENOUS PRESSURE
>The color of the tongue & the conjuctiva are more (ENGORGEMENT OF NECK VEINS)
reliable than other sites in adults while in children,
NECK VEINS
palms & soles are to be specially looked for.
1.Engorged/ Not engorged
>In scleroderma, due to symblepharon, you can not see
2.If engorged-
pallor in eye since you can not retract the lower lid. 1.JVP is raised ____cm above the sternal angle
>TELL THAT THERE IS MILD/ MODERATE /SEVERE 2.Abdominojugular reflux-Positive/ Negetive
PALLOR. DO NOT TELL THAT PALLOR IS PRESENT.
MEASUREMENT OF JVP
5.ICTERUS
a.JVP is expressed as the vertical height from the zone
-Mild/ Moderate/ Severe of trasition of distended & collapsed internal jugular
veins. The right internal jugular vein is selected because
11
it is larger, straighter & has no valves. It is situated 2.To differentiate between arterial & venous pulsation
between two heads of the sternomastoid. 3.To differentiate between obstructive & nonobstructive
causes of engorged neck vein (Negative abdomin-
b.Positioning pt while measuring JVP ojugular reflux is seen in SVC syndrome & Budd-Chiari
syndrome)
Usually the pt is made to lie in a reclined position at an >During examination of the neck veins (Jugular vein) in
angle of 45 degree woth the bed. Then the level of the examination, always ask for the backrest. If
venous engorgement of jugular vein in relation to the backrest is not supplied, then support the patient’s
sternal angle is measured with the help of two plastic trunk on your left arm to make an angle of 450 .
rulers-One ruler is placed vertically over the sternal >Normal JVP is 3-5 cm above the sternal angle (with
angle while the other ruler is placed horizontally from the Pt. at 450 to horizontal.)
the top of the oscillating venous coloumn upto the first >Engorgement of veins in the neck is a striking feature
ruler (the two ruler are held perpendicular to
of CHF.
eachother). The point at which the two ruler meet is
marked & the vertical distance from this point to the
KUSSMAUL’S SIGN (=VENOUS PULSUS PARADOXUS)
sternal angle is measured which is expressed as JVP in
cm above the sternal angle. In general, for In severe CCF & normally healthy persons, the jugular
positioning the patient, the lower the pressure in venous pressure falls on deep inspiration due to suking
the venous system, the more supine the patient’s of the blood into the right atrium. Reverse happens after
position should be;the higher the pressure, the deep expiration. But in constrictive pericarditis,
more vertical (upright) the pt’s positon should be. pericardial effusion or right ventricular infarction (or
severe right sided heart failure), there is paradoxical
c.When the JVP is grossly elevated, the jugular vein
rise in JVP after deep inspiration due to
may be engorged right upto the angle of the jaw even
nonaccomodation of increased venous return into the
when the patient sits up. Add 5 with JVP value to get
right side of the heart. This is called as Kussmaul’s sign
mean right atrial pressure in terms of centimeters of
& is also known as venous pulsus paradoxus. So
blood which can be converted to mm of Hg by KUSSMAUL’S SIGN is An increase rather than the normal
multiplying 0.736. decrease in the CVP (i.e JVP) during inspiration. In
otherwords, engorgement of jugular vein increases
d.If JVP is highly raised and could not be during inspiration & decreases during expiration.
measured, then tell, “JVP is raised beyond the KUSSMAUL’S SIGN is frequently found in constrictive
angle of the mandible OR Upper boder of jugular pericarditis or rt ventricular infarction.
venous pulsation is not seen”.
ABDOMINOJUGULAR REFLUX=HEPATOJUGULAR REFLUX 8.LYMPH NODE ENLARGEMENT
In a pt suspected of right ventricular failure who has Cervical/ Axillary/ Inguinal/ Popliteal/ Epitrochlear/
normal CVP at rest, the abdominojugular reflux test may Para-aortic
be helpful. Turn the pt’s head toward the lt side to 1.Site
expose the rt jugular vein. The palm of the examiner’s 2.Temperature
rt hand is placed over the abdomen & firm pressure is 3.Tenderness
applied in the periumbilical area for 10 s or more while 4.Number
the examiner looks at the rt jugular vein. In normal 5.Size
persons, this maneuver does not alter the JVP 6.Shape
significantly i.e. JVP rise transiently for < 15 s by < 4 7.Extent
cm & falls down even when pressure is continued. But 8.Surface
when the rt heart function is impared, the upper level of 9.Margin-Discrete/Confluent
the venous pulsation usually increases. A positive 10. Consistency (Palmar aspect of three fingers)-Soft/
abdominojugular test is best defined as an increase in Elastic & rubbery/ Firm, discrete & shotty/ Stony hard
JVP during 10 s of firm midabdominal compression / Variable/ Hard/ DiscreteMobility-Movable/ Fixed
followed by a rapid drop of pressure of 4 cm blood on 11. Fixity to surrounding skin-Yes/ No
release of the compression. The most common cause of 12. Matting-Present/Absent
a positive test is right sided heart failure secondary to 13. Examination of draining LNs
elevated left heart filling pressure. Abdominojugular 14. Examination of LNs in other parts of body
reflux is positive in right or left heart failure and/or
tricuspid regurgitation. In the absence of these >Lymphadenopathy=Adenopathy
conditions, a positive abdominojugular reflux suggests
an elevated pulmonary artery wedge pressure or central SIGNIFICANT LYMPHADENOPATHY
venous pressure. It is negative in Budd-Chiari
syndrome. It means lymph node size > 2 cm in inguinal region &
>1 cm in other region.
IMPORTANCE OF ABDOMINOJUGULAR REFLUX
LOCALISED LYMPHADENOPATHY
1.To diagnose incipient (early stage) right heart failure (=REGIONAL LYMPHADENOPATHY
(CCF)

12
Involvement of lymphnode of a single anatomic area. EXAMINATION OF CLUBBING
GENERALISED LYMPHADENOPATHY A.First step-Bring the Pt’s finger at your eye level & look
tangentially. Observe the onychodermal angle. If the
0
Involvement of three or more noncontiguous lymph angle is 180 or more, it is said that clubbing is present.
node areas. Onychodermal angle is the angle formed between the
nail & nailbed. It is also known as Lovibond’s angle.
9.THYROID SWELLING The normal onychodermal angle is approximately 1600 .
Clinically onychodermal angle is judged by the angle
1.No Thyromegaly formed between the nail & adjacent skinfold. Thus the
2.Thyromegaly other name of clubbing is Lovibond’s sign.
1.Size-
2.Shape- B.Very early clubbing can be detected by increase in
3.Thrill over the thyroid-Present/ Absent fluctuation of the nailbed i.e fluctuation is the very early
sign of clubbing. To elicit fluctuation, Pt’s finger (say the
10.CLUBBING(=LOVIBOND’S SIGN) middle finger) is placed on the pulp of the examiner’s
two thumbs (with palmar aspect of the thumbs facing
1.Unilateral/ Bilateral upward) & held in this position by gentle pressure
2.Unidigital/ Multidigital applied with the tips of the examiner’s middle fingers of
3.Painful/ Painless both hand on the Pt’s proximal interphalangeal joint.
4.Drum stick type/ Parrot beak type Now the nail base of the Pt’s finger is palpated by the
5.Onychodermal angulation-Intact/ Lost tips of the examiner’s two index finger of both hand &
6.Fluctuation test-Positive/ Negative observe for fluctuation. There is always some amount of
7.Degree of clubbing-1st /2nd / 3rd fluctuation present in normal fingers. When fluctua-tion
8.Central cyanosis-Present/ Absent is obvious due to clubbing, palpation of the nailbed may
9.Dyspnea-Present/ Absent give the impression that the nail is floating on its bed.
DEGREE OF CLUBBING C.Place the nails of the two identical fingers (preferably
THUMBS OF TWO HANDS) face to face & look for the
1.FIRST DEGREE diamond shaped area formed between the two nails &
the proximal nail folds. The normally formed diamond
Increased fluctuation of the nailbed with loss of onycho- shaped area is obliterated in the presence of clubbing.
dermal angle. This is known as SCHAMROTH’S SIGN.
2.SECOND DEGREE >For detection of clubbing, first examine the

onychodermal angle & then the fluctuation.
First degree + increase in anterop-osterior & transverse
diameter of the nails.The nails become smooth & glossy D.PROFILE SIGN
with loss of longitudinal ridges.
Definite firm transverse ridge at the root of the nail best
3.THIRD DEGREE observed on the dorsal aspect of the fingers.
Second degree + increased pulp tissue > MOST RELIABLE EARLY SIGN OF CLUBBING IS THE
LOSS OF NORMAL ONYCHODERMAL ANGLE.
4.FOURTH DEGREE
>Most reliable early sign of clubbing is loss of
Third degree + swelling of wrist & ankle due to
hypertrophic osteoarthropathy(HOA). onychodermal angle. The earliest sign of clubbing is
increased fluctuation of nailbed though not always
HYPERTROPHIC OSTEOARTHROPATHY (HOA) reliable.
>Usually the thumb & index fingers are affected first in
It is a painful swelling of the wrist, elbow, knee & ankle clubbing. Clubbing first appears in the index finger. The
with radiographic evidence of subperiosteal new bone minimum duration required for clubbing to manifest is
formation. It can be familial or idiopathic. Other 2-3 weeks.
common disorders that produce it are >After examination of one hand for clubbing, examine
a.Bronchogenic carcinoma the other hand & next examine the toes.
b.Cystic fibrosis >Clubbing within 24 hrs occurs in Empyema Thoracis.
c.Neurofibroma
d.Arteriovenous malformations 11.KOILONYCHIA
>When examining a pt for clubbing, always look for any
swelling of wrist or ankle. If wrist & ankle are swollen, >Bring the Pt.’s fingers at your eye level & look
then clubbing is of fourth degree. tangentially (as you do in clubbing). Observe & palpate
>Tell only clubbing present or absent. Do not mention the nail plates for any flattening or spooning. Tell when
about Drumstick type/ Parrot beak type. present. Otherwise, don’t tell.

13
>Koilonychia is a spoon-shaped deformity of the nail
usually found in chronic iron deficiency anemia. >In case of bilateral leg edema, ask the pt on which leg
Koilonychia develops as a result of retarded growth of edema appeared first.
the nail plate. >Whenever there is bilateral pitting pedal edema,
do not tell about sacral edema. You will search for
STAGES OF KOILONYCHIA & tell about sacral edema only when there is no
appreciable edema in lower limbs.
1.FIRST STAGE
13.CONDITION OF SKIN
Stage of brittleness, where the nail becomes brittle &
rough. 1.Scratch marks
2.Spider angioma (=Spider nevus)
2.SECOND STAGE 3.Palmar erythema
4.Purpura/ Ecchymoses
Stage of flattening, where the nail is thin, flat & without 5.Scabies/ Pyoderma/ Impetigo
longitudinal ridges. 6.Loss of skin turgidity & elasticity
7.Erythema nodosum/ Folicular hyperkeratosis/
3.THIRD STAGE Xanthoma/ Colour/ Texture/ Skin rash/ Nodules/
Pigmentation/ Eczema/ Neuroectodermal dysplasia/
4.Stage of spooning, where the nail becomes concave. Nevi
>Tell when above features are present. Otherwise, don’t
12.EDEMA OF DEPENDENT PARTS tell. Scratch marks are found in case of obstructive
jaundice & loss of skin turgidity occurs in dehydration.
1.Site-Face/ Leg
>Skin changes in Kwashiorkor-Pigmentation, thickening,
2.Bilateral/ Unilateral
erythema, cracks, desquamation, & ulcers. Skin changes
3.Pitting/ Non pitting
are classically seen on the legs, buttocks, perineum &
extensor surfaces. In moderate cases, there is a special
>Edema is seen at the following places-Apply firm
type of dermatosis known as crazy pavement skin.
pressure for few seconds (at least for 30 seconds) by
the tip of the right thumb sequentially over the dorsum 14.CONDITION OF
of foot, medial malleolus, above the medial malleolus,
medial surface of the lower end of the tibia. Now inspect a.HAIR
& palpate the area for any depression. Do the same
manoeuvre on the opposite side. Then turn the Pt to Lt. 1.Color
lateral or prone position & press the tip of right thumb 2.Texture
over sacrum. SACRUM MUST BE EXAMINED IN ALL 3.Strength-Strong/ Brittle
PATIENTS WITH EDEMA. Sacral edema is found in 4.Loss of body hair
prolonged bed ridden pt. 5.Hirsutism-Present/ Absent
EXAMINATION FOR PARIETAL EDEMA HAIR CHANGES IN PROTEIN-ENERGY MALNUTRITION
Edema of the parieties (eg.abdominal wall) is assessed In kwashiorkor, the hair becomes fine, brittle, straight,
by pinching the skin at the flanks with rt thumb & rt lustureless & sparse. There are varieties of pigmentary
index finger for few seconds (AT LEAST FOR 5 changes from brown to grey to blonde type. Often there
SECONDS). [Other methods- Press the diaphragm of the is a pale band across the black hair & is known as flag
stethoscope or the tip of fingers on the abdominal sign. In marasmus, modified hair texture is found.
parieties or thigh for a few seconds (AT LEAST FOR 5
SECONDS) & look for pitting edema there.] >In SLE, there is loss of hair (i.e alopecia is seen)
>Edema can be recognised by the pallid (i.e pale) & b.NAIL

glossy appearance of the skin over the swollen part, by
its doughy feel & by the fact that it pits on finger -Clubbing/ Flattening or koilinychia/ White nail or
pressure. Leuconychia/Splinter hemorrhage/Transluscent bands
>Observe carefully for puffy face, puffy lower lids & >Tell when present. Otherwise, do not tell. In SLE, there
scrotal edema. Edema may be seen over sternum & is loss of hair i.e alopecia is found.
forehead in a case of anasarca.
15.TONGUE
1.PRETIBIAL-Press over medial surface of the
lower end of the tibia -Glossitis/ Papillary atrophy/ Ulcers/ Dry
1.Dry tongue-Dehydration, atropine administration,
2.PEDAL-Press over dorsum of foot. mouth breathing
2.Pale tongue-Anemia
3.PRESACRAL-Press over sacrum in left or right lateral
position in prolonged bed-ridden patient.

14
3.Bald tongue-There is total loss or atrophy of papillae & >While describing the pulse rate, tell only in the
is classically seen in pellagra, pernicious anemia & iron even number.
deficiency anemia.
4.Angry looking tongue-It has central coating with red METHOD OF EXAMINATION OF PULSE
tip & margins classically seen in enteric fever.
*Tell when present. Otherwise, do not tell in the exam. The radial pulse at the wrist is generally examined with
the pulp of three fingers (index, middle & ring fingers).
16.ANGLE OF MOUTH The pt’s forearm will be semipronated & the wrist is
slightly flexed. The rate & rhythm is better palpated in
-Angular stomatitis/ Cheilosis the radial artery while volume of the pulse is better
*Tell when present. Otherwise, do not tell. palpated in the carotid artery, as it is the nearest pulse
>Riboflavin deficiency- Glossitis, angular stomatitis & to the aorta.
cheilosis.
>Look for angular stomatitis and cheilosis in case of PROPORTIONATE TACHYCARDIA
anemia hypoproteinemia.
Rise in temperature by 10 F raises the pulse rate by 10
>Angular stmatitis & glossitis is found in deficiency of
bpm.
iron, folate, vit B12, vit B2 & niacin deficiency.
>Angular stomatitis refers to cracking of the epithelium DISPROPORTIONATE TACHYCARDIA
at the edges of the lips & is caused by deficiency of iron,
riboflavin, pyridoxine, niacin & herpes labialis at the Rise in temperature by 10 F does not raises the pulse
angle of the mouth. Angular stomatitis is associated rate by 10 bpm i.e rise in temperature by 10 F raises the
with the cheilosis in niacin deficiency & Pellagra. pulse rate by either >10 bpm or < 10 bpm.
17.OTHERS RELATIVE TACHYCARDIA
a.BITOT’S SPOT Pulse rate rises > 10 bpm per degree (F) rise of
temp.Usually to calculate relative tachycardia, normal
-Present/ Absent pulse rate is taken as 72 bpm.
>Ask the patient to look medially. Look for the Bitot’s
spot on the bulbar conjunctiva in the palpebral fissure. RELATIVE BRADYCARDIA
Bitot’s spot are frequently bilateral. (TEMPERATURE-PULSE DISSOCIATION)
*Tell when present. Otherwise, do not tell.
>Look for Bitot’s spot in case of anemia hypoprotein- Pulse rate ls raised by < 10 bpm per 0F rise of temp.
emia. Usually to calculate relative bradycardia, normal pulse
>Vitamin A deficiency-Bitot’s spot & follicular hyperkera- rate is taken as 72 bpm.
tosis.
>Shock is defined as pulse rate 100 bpm & SBP <100
b.XANTHELESMA mm of Hg.
c.PAROTID SWELLING b.RHYTHM
d.GYNECOMASTIA (Spacing of successive beats in time in Radial artery)

When the disc size of the breast is more than the areola 1.Regular
or the diameter of the disc is > 4 cm. It is commonly 2.Irregular
found in CHF pt (due to MS or congenital heart disease) 1.Regularly irregular-Irregularity comes at regular
taking digitalis for a prolonged period. intervals
2.Irregularly irregular or completely irregular-Irregul-
e.SPIDER NAEVI arity between two pulses beats in every aspect i.e.
volume, spacing etc. i.e totally chaotic.
19.VITALS (Do not utter the word vitals in the exam.)
>Whenever you are finding irregular pulse, you
A.PULSE must count the pulse deficit & tell.
a.RATE PULSE DEFICIT = APEX-PULSE DEFICIT
:____ bpm (Radial artery) It is the difference between the heart rate & the pulse
rate when counted simultaneously for full 1 minute. But
1.Tachycardia- >100 bpm for our convenience, we determine pulse deficit in two
2.Bradycardia- < 60 bpm minutes. First count the heart rate for 1 minute using
>Normal pulse rate is 60 -100 bpm the diaphragm of the stethoscope placed over the mitral
>Always count the beats for not less than 30 SECONDS, area & then count the pulse rate for 1 minute in radial
artery. Then find out the difference between the two
but in arrhythmia count for full 1 MINUTE.
rates. If pulse deficit is > 10 bpm, it is due to atrial

15
fibrillation (AF). If pulse deficit is < 10 bpm, it may be pulses are palpable & equally felt on both sides. You
due to multiple ectopics or atrial fibrillation. If must describe this point always. It includes the pulses of
pulse rate is >100 bpm & pulse defict > 10 bpm, atrial both upper & lower limbs.
fibrillation is confirmed. If pulse rate is < 100 bpm, it
>In case of edema, press the edema fluid for a few
may be due to atrial fibrillation or multiple ectopics.
>Pulse deficit is commonly found in atrial fibrillation & seconds for better palpation of peripheral pulses.
multiple ectopic beats.
DEMONSTRATION OF WATER HAMMER PULSE
c.VOLUME [Carotid artery (Right)] (=COLLAPSING PULSE)
Water hammer pulse is best felt in the radial artery with

• Good Volume (Tell in a normal case)
the pt’s arm elevated. Stand on the rt side of the pt.
• High Volume (Pulse pressure > 60 mm of Hg)
Grasp the pt’s rt forearm just below the wrist joint with
• Low Volume (Pulse pressure < 30 mm of Hg) your rt hand in such a way that the palmar aspect of the
head of the metacarpals overlie the radial artery & rest
d.CHARACTER [Carotid artery (Right)] of the palm lies over the ulnar artery. Examine the
volume of the pulse for a few seconds. Now elevate the
Normal/ Bounding/ Collapsing or Water hammer Pulse/ whole upper limb (with support at the elbow to prevent
Plsus alternans/ Pulsus bigeminus/ Pulsus paradoxus/ flexion) suddenly above the shoulder & try to feel any
Bisferiense pulse changes in the volume of the pulse.For examination of
the pulse in this way,the examiner stands within the
>The rate & rhythm are better palpated in RADIAL angle formed between the Pt’s body & the said upper
ARTERY while volume & character in CAROTID ARTERY extremity. The rt sided pulse should be examined by the
(it is the nearest pulse to the aorta). rt hand while standing on the Rt. side & the lt sided
>Usually palpation of peripheral arterial pulses such as pulse should be examined by the lt hand while standing
radial artery gives less information than examination of on the lt side. If water hammer pulse is present, the
a more central pulse (carotid pulse) regarding pulse volume increases from the basal level (i.e the
alterations in left ventricular ejection or aortic valve volume before elevating the upper limb at the beginning
function. However, certain findings like Bisferiens pulse of the examination before elevating the upper limb)
of AR or pulsus alterans are more evident in peripheral after elevation of the upper limb. The pulse strikes the
arteries. palpating finger with a rapid forceful jerk & quickly
disappears. The term collapsing pulse is used because
e.RADIO–FEMORAL DELAY/ RADIO-RADIAL DELAY the artery completely empties between the two beats
giving an impression to the palpating palm that the
-Present/ Absent pulse has collapsed. The collapsing nature is often
>For detection of Radio-Femoral delay, one should reliably detected by palpation of the carotid artery.The
palpate the radial & femoral artery simultaneously by upper limb is elevated during the examination, because-
placing the left hand fingers on the right radial artery & 1.When the upper limb is elevated, there is fall of
right hand fingers on the right femoral artery. blood coloumn resulting in vasodilation & thus helps
Conditions having radio-femoral delay are Coarctation of to reduce the diastolic blood pressure more, so that
aorta. the pulse pressure (i.e SBP-DBP) widens. More is
>Radio-Radial delay-Simultaneously palpate both the the pulse pressure, betrer is the water hammer
radial arteries by both of your hands, using your lt hand pulse felt.
for patient’s rt hand & your rt hand for pt’s lt hand. 2.When the upper limb is elevated, the radial artery
Conditions having radio-radial delay are Subclavian palpated becomes more in the line of the aorta
artery thrombosis, Raynaud’s phenomenon. thereby allowing direct systolic ejection of blood into
the radial artery during systole & direct diastolic
f.CONDITION OF ARTERIAL WALL backward flow of blood from the radial artery during
diastole.
-Arterial wall is just palpable (in normal case)/
Thickened (Arteriosclerosis in old age) >WATER HAMMER PULSE IS CHARACTERIZED BY: HIGH
VOLUME & SHARP RISE (large bounding pulse) and
METHOD TO ASSESS THE CONDITION OF THE ILLSUSTAINED & SHARP FALL. High volume is due to
ARTERIAL WALL increased stroke volume. The stroke volume is increased
because the left ventricle gets blood from two sources
First place the index & middle fingers of both the Lt. i.e blood leaking from the aorta & the blood from the
hand & Rt. hand over the radial artery side by side & left atrium. Sharp rise is due to decrease in the
exsanguinate the artery by moving the two middle peripheral vascular resistance. The peripheral vascular
fingers in opposite direction. The radial artery is now resistance decreases because the increased stroke
rolled over the radius by two index fingers. volume & hence the increased cardiac output stimulates
the baroreceptors in the aortic arch causing reflex
g.SYMMETRY vasodilation which in turn decreases the peripheral
resistance. Illsustained & sharp fall i.e collapse occurs
Check out whether the same pulse on both the sides are because-1. Blood leaks into the left ventricle from the
palpable with equal magnitude or not. All peripheral aorta during diastole (i.e Aortic run off), 2. Rapid run off
16
of blood to the periphery from the palpated artery due tortuous pulsating Brachial artery at the inner
to low peripheral vascular resistance explained earlier. (medial) side of the upper arm.
>Diastolic pressure can not be felt while palpating for 3.SUBCLAVIAN ARTERY
Water hammer pulse. PRESENCE OF WATER HAMMER
PULSE IS CONFIRMED BY SPHYGMOMANOMETER BY • Feel just above the middle of the clavicle with the
MEASURING PULSE PRESSURE (I.E SBP-DBP) WHICH IS pulp of the fingers.
USUALLY GREATER THAN AT LEAST 60 mm OF Hg.
C.LOWER LIMB
METHODS TO PALPATE PERIPHERAL PULSES 1.DORSALIS PEDIS ARTERY
PRINCIPLE : The arterial pulse is to be felt by
• Feel at the middle of the dorsum of the foot just
compressing the concerned artery against a bony lateral to the tendon of extensor hallusis longus. Best
prominence. felt at the proximal extent of the groove between the
first & second metatarsus.
A.HEAD & NECK • It is absent in 10% of cases & is abnormally located
in 10% of cases.
1.COMMON CAROTID ARTERY
2.POSTERIOR TIBIAL ARTERY
• Use lt thumb for rt carotid artery & rt thumb for lt
carotid artery. Place the pulp of the thumb between • Feel 2cm below & 2cm behind the medial malleolus.
the thyroid cartilage (Upper border of thyroid
cartilage) & the anterior border of sternomastoid 3.ANTERIOR TIBIAL ARTERY
muscle. Press the thumb gently backwards (against
the CAROTID TUBERCLE of the 6th vertebra) to feel • Feel at the lower end of the tibia just above the ankle
the pulse. joint & just lateral to the tendon of extensor hallusis
• Examine for volume, character & bruit in carotid longus which is made taut by asking the patient to
artery. extend his great toe.
2.SUPERFICIAL TEMPORAL ARTERY 4.POPLITEAL ARTERY
• Feel the artery with the pulp of the fingers just in • Preffered method-Flex the knee to 400 (or 300) &
front of the tragus of the ear. make sure the pt is relaxed. Place the thumbs of
• Tortuosity of this artery is a feature of atherosclero- both the hands in front of the knee & place other
sis. fingers of both the hands behind the knee in the
lower part of the popliteal fossa. Press firmly & move
3.FACIAL ARTERY the pulp of the fingers side to side against the
posterior aspect of tibia in the lower part of the
• Feel the artery on the mandible at the antero-inferior popliteal fossa (Feel the pulse 3-4cm below the knee
angle of the masseter. crease). Popliteal artery lies on the lateral side of
the lower part of the popliteal fossa.
B.UPPER LIMB • Alternative method-Patient lies in prone position.
Feel the artery with the pulp of the fingers after
1.RADIAL ARTERY flexing the knee passively with another hand.
• Wrist is slightly flexed & forearm is semipronated. 5.FEMORAL ARTERY

Feel at the wrist on its volar (=ventral) aspect on the
lateral side with the pulp of three fingers i.e index, • Patient lies in supine position. Feel the artery with
middle & ring finger. the pulp of the fingers in the groin just below the
• Examine for rate & rhythm in radial artery. inguinal ligament midway between the anterior
superior iliac spines & the symphysis pubis (i.e mid-
2.BRACHIAL ARTERY inguinal point). In obese patient, it is difficult to feel
the femoral artery pulsation.
• Place the thumb in the antecubital fossa in front of
the elbow (rt thumb for rt arm & lt thumb for lt arm.) • Examine for RADIO-FEMORAL DELAY & BRUITS IN
Feel the artery with the pulp of the thumb just FEMORAL ARTERY.
medial to the biceps tendon.
• LOCOMOTOR BRACHIALIS
It is a feature of atherosclerosis. For demonstration,

flex the upper limb at the elbow & externally rotate
the flexed upper limb at the shoulder. Look for the

17
GRADING OF PULSES 5.During deflation, Korotokoff sounds having following
phases are heard
TRADITIONAL BASIC 1.Phase I-Sudden appearance of the faint, clear,
4+ Normal tapping sound which indicates SBP.
3+ Slightly reduced 2.Phase II-Murmurs or swishing like sounds replace
2+ Markedly reduced Normal the tapping sound
1+ Barely palpable Diminished 3.Phase III-Gong or Crisper sound which is more
0 Absent Absent intense than murmur replaces murmur
4.Phase IV-Loud sound suddenly becomes muffled
(i.e distinct, abrupt muffle of sound)
B.BLOOD PRESSURE
5.Phase V-Absence of all sounds which indicates
diastolis blood pressure in adult & in pre-eclamsia.
a.________mm Hg
>Do not tell blood pressure is x mm of Hg in right arm
6.Read BP to the nearest 2 mm of Hg. Two readings
in supine position, because it is assumed that you
should be performed at least one minute apart.
measured blood pressure in right arm in supine position.
7.Onset of phase-I Korotokoff’s sound corresponds to
systolic blood pressure.
METHOD TO MEASURE BLOOD PRESSURE IN
8.In adult, the DBP should be recorded at Korotokoff
UPPER LIMB phase V (i.e disappearance of sounds) & not phase IV
(muffling of sounds). In children, the DBP should be
Follow the following steps recorded at Korotokoff phase IV (i.e muffling of
1.Pt should lie in supine position ( as SBP may rise after
sounds)
sitting or standing ) with the legs uncrossed & should
9.Muffling of sound i.e phase –IV sound is recorded as
take rest for 5 minutes before recording blood diastolic blood pressure when diastolic pressure is
pressure at that position ( BP should be recorded with
found to be zero.
the pt taking rest in a comfortable position & thus 10. Take two measurements at each visit. Repeat
casual recording should always be avoided ).
measurement after 5 minutes of rest if the first
recording is high.
2.First remove the tight clothing from the upper arm.
11. Standing blood pressure should be measured in
Wrap the cuff firmly & uniformly over the upper arm in
elderly subjects, diabetics & those who are suffering
such a way that it allows only enough room for one from postural hypotension.
finger to be slipped between the cuff & skin surface.
12. Postural hypotension is defined as a drop in systolic
The lower border of the cuff should remain at least 1 pressure of greater than equal to 20 mm of Hg on
inch above the elbow joint. Use cuff of appropriate
standing from the supine position i.e SBP in supine
size i.e the cuff must encompass more than two-
position – SBP in standing position ≤ 20 mm of Hg
thirds of the upper arm. An ideal cuff should cover
suggests postural hypotension.
two-third of arm circumference. The cuff must be
13. To avoid spuriously high recordings in obese pt, the
placed at the heart level to obtain a pressure that is
cuff should contain a bladder that covers at least
uninfluenced by the gravity. Cuff size refers only to
2/3rd of the circumference of the upper arm.
dimensions of the bladder or the inflatable pneumatic
14. Blood pressure is usually measured in the rt arm
cavity of the cuff & does not refer to the entire cuff.
with the pt lying on her side at 30 degree to the
The proper cuff size needed is determined by the
horizontal. In the OPD sitting posture is preffered. In
dimensions of the limb that is used to measure the
either case the occluded brachial artery should be
blood pressure. The ratio of the width of the cuff to
kept at the level of heart.
the circumference of the extremity is of critical
importance for accurate blood pressure measurement. > BLOOD PRESSURE SHOULD BE MEASURED IN ALL
CARDIOVASCULAR CASES.
3.The arm should be kept in extended position & should
be held at the level of the right atrium (Support the METHOD TO MEASURE BLOOD PRESSURE IN
upper arm at the level of the heart). Keep the blood LOWER LIMB
pressure instrument at the level of the pt’s heart.
Raise the pressure to 30 mm of Hg above the point at Pt lies in prone position. Tie the sphyg-momanometer
cuff in the mid-thigh. Put the diaphragm of stethoscope
which radial pulse disappears. Now start deflating at a
rate of 2 to 3 mm/second & the point of in the popliteal fossa over the popliteal artery after
reappearance of the radial pulse indicates SBP by feeling the popliteal artery pulsation.
palpatory method. >Recording lower limb blood pressure is important in
coarctation of aorta (low), aortic regurgitation (high)
4.Now place the diaphragm of the stethoscope over the etc.
brachial artery a little below the cuff (Auscultatory
method). The cuff is inflated again & the mercury AUSCULTATORY GAP (SILENT GAP)
coloumn is raised to 20 mm of Hg above the SBP
recorded by palpatory method. Then lower the During manual measurement of blood pressure in
mercury coloumn slowly at 2 mm/second. hypertensive individuals, the Korotkoff sounds
sometimes disappear at a pressure well above the true
diastolic blood pressure, then reappear at a lower

18
pressure & again disappear at a further lower pressure " The paradox is that the decrease in SBP may be so
ultimately indicating true diastolic pressure (Normally, high that pulse may completely disappear during
Korotkoff sounds do not disappear at a pressure well inspiration, but at the same time heart soumds may
above the diastolic pressure). This interval of pressure still be heard on auscultation over the apex when no
within which Korotkoff sounds are not heard is called as pulse is palpable on the radial artery.
ausculatory gap. Improper interpretation of this gap
leads to falsely low recording of systolic blood pressure PROCEDURE TO DEMONSTRATE PULSUS PARADOXUS
because this gap which usually occurs at a very high
pressre can be mistaken for the disappearance of Tie the blood pressure cuff in the pt 7 inflate the cuff till
Korotkoff sounds at a pressure greater than true systolic no sound is heard as you are doing during normal blood
blood pressure except that the pulse can still be pressure measurement. Now gradually deflate the cuff.
palpated. That is why, it is greatly recommended to As you gradually deflate the cuff, a point will come when
measure the blood pressure by both palpatory & you will hear Korotkoff sounds intermittently. Record
auscultatory method. First measure the blood pressure this point. As you go on deflating, a point will come
by palpatory method to know the true SBP. Then when you will hear normal continuous Korotkoff sounds.
measure the blood pressure by auscultatory method Record this point. Now calculate the difference between
during which you should raise the cuff pressure above the two points. If the difference is > 10 mm of Hg, then
the SBP obtained by the palpatory method & then pulsus paradoxus is present & if the difference is < 10
graduall lower the pressure to find out SBP & DBP. mm of Hg, then pulsus paradoxus is absent.
CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS ≥18

HILL’S SIGN
YEARS
Positive Hill’s sign is characterized by increase in the CATEGORY SBP DBP
femoral artery systolic BP by > 20mm of Hg above the Optimal < 120 < 80
brachial artery systolic BP. Normally, the difference in Normal < 130 < 85
SBP remains within 20mm of Hg (while the diastolic BP High Normal 130-139 85-89
is same in both upper & lower limbs). In severe AR, the Hypertension 140-159 90-99
increase is > 60 mm of Hg. It is very important & Stage 1 (Mild)
specific sign of AR. Hypertension 160-179 100-109
Stage 2 (Moderate)
PULSUS PARADOXUS (= PARADOXICAL PULSE = Hypertension ≥ 180 ≥ 110
PULSUS NORMALIS AGGREGANS) Stage 3 Severe)
Isolated systolic ≥ 140 < 90
" It is an inspiratory decline in systolic blood pressure > hypertension
10 mm of Hg. It represents an exaggeration of the
normal decline in systolic blood pressure during
inspiration & therefore, it is not truly paradoxical. As it NOTE: The above classification of blood pressure is for
is an aggravation of a normal process, it is also called adults aged 18 years & older not taking
as PULSUS NORMALIS AGGREGANS. antihypertensive drugs & not acutely ill, and is based on
" During inspiration, intrathoracic pressure becomes the average of ≥2 readings taken at each of two or
negative # Blood is sucked from the abdomen into more visits after an initial screening. When systolic &
the thorax # Venous return to the rt heart is diastolic pressures fall into different categories,
increased # Increased blood flow through the rt heart the higher category should be selected to classify
due to increased venous return pushes the the individual’s blood pressure status.
interventricular septum towards the lt side therby >Normal SBP is 100 to 140 mm of Hg, Normal DBP is 60
decreasing the lt ventricular volume & hence lt to 90 mm of Hg & Normal pulse pressure is 30 to 60
ventricular filling decreases # Cardiac output
mm of Hg.
decreases # Sustolic blood pressure (SBP) decreases.
This is called Reverse Berheim Effect.
C.RESPIRATORY RATE
" During inspiration, intrathoracic pressure becomes
negative. Leading to pulmonary venous pulling i.e
a.____/min-Tachypnea/ Bradypnea
blood remains in the pulmonary venous system #
>Normal respiratory rate is 14-20/minute. The ratio of
Pulmonary venous return into the lt heart decreases #
Blood flow into the lt ventricle decreases # Cardiac normal respiratory rate to normal pulse rate is 1:4.
output decreases # Sustolic blood pressure (SBP) >Tachypnea is an increased respiratory rate observed
decreases. by the doctor, while dyspnea is a symptom of
" Normally the decrease in the SBP due to the breathlessness i.e shortness of breath experienced by
aforementioned two reasons is < 10 mm of Hg. When the pt. Apnea means cessation of respiration
decrease in the SBP is > 10 mm of Hg, it is called as
PULSUS PARADOXUS, which occurs in conditions b.Type-Abdominothoracic/ Thoracoabdominal/
where lt ventricular filling is compromised leading to Exclusively abdominal
but exaggeration of normal phenomenon occurring l
during inspiration e.g cardiac tamponade, constrictive >Always count respiratory rate for full 1 MINUTE after
pericarditis, acute severe asthma (=status placing fingers on radial artery to bias the Patient or
asthmaticus).
19
place a pen on the patient’s abdomen & then count the 2.TERTIAN-The paroxysm of fever occurs on
respiratory rate. alternate day i.e after a gap of 48 hrs.
>Normal rhythm of breathing is characterized by
Inspiration#Expiration#Pause. Reversed respiratory 3.QUARTAN-The paroxysm of fever occurs after a
rhythm i.e Expiratory grunt#Inspiration#Pause is seen gap of 2 days i.e 72 hrs intervene between 2
in children with acute lower respiratory tract infection. consecutive paroxysms of fever.
0
>Per F rise of temperature, respiratory rate increases
by 2-3 breaths/minute. 2.CONTINUED
TYPE OF RESPIRATION Fever does not fluctuate more than 10C (1.50F) during
the 24 hr period & never touches the baseline.
1.Thoracic-Adult women, huge ascites, peritonitis,
diaphragmatic palsy 3.REMITTENT
2.Abdominal-Adult men, pleurisy, young children
3.Abdomino-thoracic-Young children, sometimes in Daily fluctuation of fever is more than 20C (30F) & never
adult men touches the baseline.
3.Paradoxical respiration-Diaphragmatic palsy
4.Females with predominantly abdominal type of TEMPERATURE RANGES
respiration-Any painful condition in the chest e.g
RANGE CENTIGRADE FARENHIT
pneumothorax, pleurisy, chest trauma
5.Males with predominantly thoracic type of respiration-
NORMAL 36.60-37.20 980-990
Any painful condition in abdomen e.g huge ascites, SUBNORMAL <36.60 <980
acute peritonitis FEBRILE >37.20 >990
HYPERPYREXIA >41.60 >1070
>Tachypnea=Polypnea-Indicates increase in the rate of HYPOTHERMIA <350 <950
respiration.
>Hyperpnea-Increase in the rate & depth of the
respiration (Increased ventilation is due to increase
metabolic needs). I.SYSTEMIC EXAMINATION
D.TEMPERATURE
CVS EXAMINATION
0
: _____ F
RESPIRATORY SYSTEM & GASTROINTESTINAL SYSTEM
(to find out tender hepatomegaly, ascites etc.)
>Tell temperature only if you have measured. Otherwise SHOULD BE EXAMINED IN ALL CVS CASES.
do not tell. Do not tell-Pt. is afebrile. In the
examination, measure the oral temperature, not the >Precordium-Area of the anterior chest wall overlying
axillary temperature. Tell the exact value of tempera- the heart on the left side.
ture. If the temperature is normal, tell it as 99.2 F or
99.6 F. Don’t use the words like low grade or high grade
fever. I.INSPECTION (OF PRECORDIUM)
>Oral temperature is measured by placing the
thermometer under the tongue while the pt breathes 1.SHAPE & SYMMETRY OF THE CHEST
through the nose with lips firmly closed. It reflects the
core body temperature. a.Bilaterally symmetrical
>The axilla or groin with thigh flexed over the abdomen b.Precordial Bulging/ Bulging of intercostals spaces /
Kyphosis/ Scoliosis
is also convenient to measure temparature in an
>Precordial bulging occurs as a sign of long standing
unconscious pt.
>The axilla or groin with thigh flexed over the abdomen cardiac enlargement due to soft rib cage.
>Bulging intercostals spaces-Pericardial effusion,
to measure temparature is preffered in infants.
empyema thorasis etc.
FEVER TYPES
TYPICAL DESCRIPTION IN NORMAL CASE-Chest is bila-
1.INTERMITTENT terally symmetrical. Do not tell-Chest is bilaterally sym-
metrical & there is no precordial bulging, because chest
Fever is present only for several hours & always touches is bilaterally symmetrical means there is no precordial
the baseline sometimes during the day. It is of 3 types bulging. Otherwise how can the chest wall be bilaterally
symmetrical with precordial bulging? So chest wall is not
1.QUOITIDIAN-The paroxysm of fever occurs daily bilaterally symmetrical when there is chest wall bulging.
i.e daily rise & daily fall of temperature.In double
quotidian fever, double fever spike occurs in a 2.PULSATION
single day.
a.No visible pulsation
b.Apical pulsation-Visible/Not visible
20
c.Visible pulsation in- Parasternal area (RVH)/ >For palpating apex beat, use the pulp of the fingers;
Pulmonary area/ Epigastrium (RVH)/ Suprasternal area/ for thrills, use the base of the fingers; for parasternal
Carotid pulsation/ heaves, use the base of the hand i.e thenar &
hypothenar eminences.
>Apical impulse-Visible cardiac pulsation. If apical
impulse is not visible in supine position, it can be visible 1.MITRAL AREA
from the Rt. side of the Pt.by tangential view. (Half inch in diameter with center at the apex of the
>The commonest cause of displacement of of the apex heart)
beat is deformity of thoracic cage usually scoliosis.
A.APEX BEAT
3.PROMINENT VEINS OVER THE CHEST WALL
1.LOCATION
-Absent
-Present-Pulsatile/ Nonpulsatile -5th ICS 1 cm medial to MCL/ Displaced-Inside or
outside the MCL/ ___th ICS inside or outside the MCL
4.SCAR MARK/SINUS OVER THE CHEST WALL >It is the lowermost & outermost part of the precordium
where a DEFINITE BUT NOT NECESSARILY THE
II.PALPATION MAXIMUM thrust that can be felt.
>Pt lies in supine position. Stand on the rt Side of the
COUNTING OF THE RIBS & ICS Pt. Place your palm firmly over the precordium. Try to
feel the definite thrust (not nessarily the maximum)
First place the rt index finger in the suprasternal notch palpable with the pulp of the fingers & locate it with the
& then go downwards till the sternal angle is reached rt index finger in the ICS by counting ribs from the
which is felt as a transverse ridge (junction of the body sternal angle (corresponds to 2nd rib) by your lt hand.
of the sternum & manubrium sterni). Now if the finger is Look how far is the apex beat from the lt MCL-
moved sideways, it will touch the 2nd rib below which Inside/Outside. To detect the character of the apex
lies the 2nd ICS.Then count the ribs with ICS from beat, press the tip of the rt index finger very firmly over
above downwards. Posteriorly, the ribs & ICS are the apical impulse.
counted from below upwards. If the Pt.’s arms lie by the >Ask the pt to sit & lean forward & try to locate apex
side of his body, the inferior angle of the scapula lies at beat as mentioned above if it is not palpable in supine
the level of T7 spine (or the 7th rib) which may help in position.
counting ribs & ICS in the back. >If still not palpable, say the apex could not be localized
properly.
METHOD OF PALPATION
>In children, apex beat is located in the 4th ICS, while
1.Place the heel of the hand over the lt sternal edge & in tall-lean persons, apex beat is located in 6th ICS.
fingertips over apex, then feel the aortic & pulmonary >In lt ventricular dilation, the cardiac apex shifts
areas by placing fingers in the intercostal spaces. downward & outward while the cardiac apex shifts only
2.Pt will sit & lean forward & hold the breath in expira- outward in case of right ventricular dilation.
tion. Standing on the rt side of the pt, put your rt >Apex beat shifted upward & outward in massive
palm over the sternum transversely in such a way that ascites.
your fingers lie over the pulmonary area, centre of the
palm rests over the sternum & thenar-hypothenar 2.CHARACTER
eminences (Heel of the palm) lie over the aortic area.
To feel for the thrills, place your right palm very firmly 1.NORMAL
over the different areas of the chest wall.
3.Diastolic thrill of mitral stenosis is best felt at the apex Just felt by the palpating finger as a brief gentle tap,
with the pt rolled on to the lt side (lt lateral recumbent not much forceful but palpable with certainty.
position) & breath held in full expiration.
4.If thrill is present, there must be a systolic murmur. 2.FORCEFUL & WELL SUSTAINED (=HEAVING)
Thrill is found mostly in case of a systolic murmur. But
thrill is also found in case of mid-diastolic murmur of Lifts your finger & stays for sometime.
MS. That means thrill usually indicates the presence of
a systolic murmur except in MS. Except mid-diastolic 3.FORCEFUL & ILLSUSTAINED (=HYPERKINETIC)
murmur of MS, other diastolic murmurs are usually
not associated with thrills. So, if you are telling about Touches the finger & reverts back.
thrill in palpation, then you have to tell about a
systolic murmur in auscultation. 4.TAPPING
>Description of thrill-If thrill is absent, tell “There is no Perceived as a definite vibratory knock without the
thrill”. But don’t tell “There is no palpable thrill”, finger being actually lifted. It is of very low amplitude
because thrill is always palpable. There is no thrill which & illsustained.
is not palpable.

21
>To note the character of the apex beat, turn the Synchronous with the carotid pulsation or apex beat, e.g
patient to lt lateral position. PS, Fallot’s Tetralogy, PDA (Sometimes continuous
>Tapping apex beat is suggestive of PALPABLE S1 (= thrill), ASD, High VSD.
TAPPING APEX BEAT) in the mitral area while heaving
apex is indicative of left ventricular hypertrophy due to 2.CONTINUOUS
pressure overload. Hyperkinetic apex beat is
characterized by exaggerated & illsustained thrust of Felt throughout the cardiac cycle e.g PDA
cardiac impulse & is seen in volume overload conditions
like anemia, AR, PDA, VSD, MR, thyrotoxicosis. 3.AORTIC AREA
(Half inch in diameter with center in the right 2nd
B.PULSATION-Present/ Absent ICS close to sternum)
C.THRILL (Palpable Murmur) A.PALPABLE A2
1.SYSTOLIC B.PULSATION-Present/ Absent
Synchronous with the carotid pulsation or apex beat, e.g C.THRILL

MR (commonest), VSD, ASD (Ostium primum type)
1.SYSTOLIC
2.DIASTOLIC
Synchronous with the carotid pulsation or apex beat e.g
Felt before carotid pulsation, e.g MS (commonest), Left AS (almost exclusively).
atrial myxoma (very rare).
2.DIASTOLIC
>In mitral area, if there is any difficulty in palpating
thrills, ask the pt to hold his breath after full expiration Felt before carotid pulsation, e.g AR (Rare)
& turn the patient to lt lateral position for better
palpation of thrills. 4.TRICUSPID AREA
>While palpating for thrills, always put your lt thumb
over the rt carotid artery at the level of the upper (Half inch in diameter with center in the lt 5th ICS close
border of the thyroid cartilage to confirm the timing. to sternum). Tricuspid area corresponds to lower lt
>Meaning of thrill-Palpable low frequency vibrations felt parasternal area.
like a purring of a cat & is always associated with heart
murmur. It is synonymous with palpable murmur. A.PARASTERNAL HEAVE
>Always remember that in mitral area, diastolic thrill is (=LEFT PARASTERNAL HEAVE)
very common while in all other areas (base of the heart
-Absent/ Present-Grade-I/ II/ III
& tricuspid area), systolic thrill is very common. In
pulmonary area, thrill may be continuous or systolo-
>Pt is in supine position. Stand on the Rt. side of the pt.
diastolic, e.g PDA.It is seen that thrill is usually present
in stenotic lesions & generally absent in regurgitant Place the entire hypothenar eminence of your palm upto
the base of the little finger (the rest part of the palm
lesions of the heart. Presence of a thrill in most of the
time indicate that the murmur is organic. should not touch the chest wall) vertically over the mid
& lower lt parasternal area with breath held in
expiration. Then look for any lifting of the hand. To
>CAREY COOMBS MURMUR & AUSTIN FLINT MUR-
grade the parasternal heave, you should firmly press
MUR ARE NOT ASSOCIATED WITH A THRILL AS
the hypothenar eminence to feel whether the heave is
THEY ARE FUNCTIONAL MURMURS & FUNCTIONAL
obliterated or not. If obliterated, it is grade-II and if not
MURMURS ARE NEVER ASSOCIATED WITH THRILL.
obliterated, it is grade-III. Never tell lt parasternal
heave, because there is no rt parasternal heave. So
2.PULMONARY AREA parasternal heave means lt parasternal heave.
(Half inch in diameter with center in the left 2nd ICS
close to sternum) GRADING OF PARASTERNAL HEAVE
A.PALPABLE P2 1.I-Felt but hand not lifted

(=PULMONARY SHOCK= DIASTOLIC 2.II-Felt & hand lifted but obliterated by applying
SHOCK=DIASTOLIC KNOCK) pressure
3.III-Felt & hand lifted but not obliterated by applying
It is found in pulmonary hypertension of any etiology. pressure
B.PULSATION-Present/ Absent >Parasternal heave is the anterior movement of lower

left parasternal area. Parasternal heave indicates right
C.THRILL ventricular hypertrophy or left atrial enlargement.
>Rt ventricular hypertrophy often results in a sustained
1.SYSTOLIC systolic lift at the lower lt parasternal area which starts
22
in early systole & is synchronous with the lt ventricular >Normally, the lt 3rd ICS is dull on percussion.
apical impulse. >Proceed from lateral side towards sternum with the
>Heave means the impulse is forceful & well sustained pleximeter finger perpendicular to rib.
while lift means the impulse is forceful but is not well
sustained. METHOD TO PERCUSS THE HEART
>The point of maximal impulse (PMI) is helpful in
determining whether the rt or lt ventricle is dominant.At first, find out the upper border of liver dullness along
In pt’s with lt ventricular dominance, the impulse is rt MCL.Now, for delineation of the rt border of heart,
maximal at the apex where as in rt ventricular select one space higher from the upper border of liver
dominance the cardiac impulse is maximal over the dullness. Keeping the pleximeter finger parallel to the
lower lt sternal border. arbitary rt border of heart, lightly percuss from rt to lt.
Actually percussion is done in the 3th & 4th ICS. As
B.PULSATION soon as dull note is obtained due to heart, mark it &
then join the points to get the Rt. border of heart. Now
C.THRILL localize the cardiac apex. For the lt border of the heart,
percuss along (or parallel to) the lt ACROMIO-XIPHOID
1. SYSTOLIC LINE (an imaginary line from the tip of the acromion
process of the lt side to the xiphisternum) in the 2d, 3rd
Synchronous with the carotid pulsation or apex beat, & 4th ICS. Now join the points of dullness with the
e.g TR, PS (Infundibular type), VSD, ASD (Ostium cardiac apex to get the lt border of heart. Lastly,
primum type) percuss the base of the heart to delineate the upper
border of heart.
>FOR DEMONSTRATION OF ANY EVENT I.E PALPATION,
PERCUSSION OR AUSCULTATION IN AORTIC OR METHOD TO PERCUSS THE BASE OF THE
PULMONARY AREA, ASK THE Pt TO SIT & LEAN FOR- HEART(OR PERCUSSION OF THE STERNUM OR ME-
WARD. YOU CAN DO IT IN SUPINE POSITION IN EXAM. DIASTINAL PERCUSSION)
5.THRILL OVER CAROTID ARTERIES Percussion is usually done in the 2nd ICS. Ask the pt to
sit. First place the PLEXIMETER finger in the aortic area
parallel to the rt sternal border. The line of percussion in
CAROTID SHUDDER the aortic area will be perpendicular to the rt sternal
border & go on percussing upto the middle of the
It is the systolic thrill felt over the carotid arteries by
sternum i.e go from rt to lt. Now place the pleximeter
placing your thumb lateral to the upper border of
finger in the pulmonary area parallel to the lt sternal
thyroid cartilage. Normally, if we place our thumb over
border. The line of percussion in the pulmonary area will
the carotid artery lightly, nothing is felt. But if carotid
be perpendicular to the lt sternal border & percuss upto
shudder is present, a thrill is felt which gives an
the middle of the sternum where you left i.e now go
impression of high volume carotid pulse to the beginner.
from lt to rt. One may percuss the aortic & pulmonary
Pulse is felt for a long time, but this thrill is felt for
areas by the above method & may stop the percussion
sometime. Tell this if present.
after reaching the rt & lt borders of the sternum
>When stethoscope is placed over the carotid artery respectively. Then percussion of the sternum is done
having carotid shudder, we will hear a murmur called as directly by the PERCUSSING FINGER(=PLEXOR FINGER)
carotid bruit. In other words, when the murmur occurs without using the pleximeter finger. Listen the
at the site of arterial stenosis, they are traditionally percussion note carefully. Thereafter percussion may be
called bruits. done in the 3rd ICS.
>BASE OF THE HEART often used clinically refers to the
6.FEEL FOR THE rt & lt second intercostals spaces close to the sternum.
A.EPIGASTRIC PULSATION
IV.AUSCULTATION
B.SUPRASTERNAL PULSATION GUIDELINES
III.PERCUSSION 1.Optimise acoustics

(usually done in pericardial effusion, otherwise it is not • Ensure the ear pieces of the stethoscope fit perfectly
done.) • Experiment with the different degrees of pressure
on the head of the stethoscope.
a.Left 2nd ICS-Resonant/ Dull 2.Time the sounds by feeling the carotid pulse.
3.Use the bell the low-pitched noises like 1st (S1), 2nd
b.Left 3rd ICS- Resonant/ Dull (S2), 3rd (S3), 4th (S4) heart sounds & mid-diastolic
murmurs.
>Normally, the lt 2nd ICS is resonant & cardiac dullness 4.Use the diaphragm for high-pitched noises like
does not extend beyond the apex. pansystolic murmurs & early diastolic murmurs.
>Second ICS is obliterated (i.e dull on percussion) in 5.Listen to the noises like a piece of music-
pericardial effusion etc. • What tune or candence you can hear?
23
• Analyse each sound separately. stethoscope. Then you auscultate the pt in left lateral
6.The best way to detect murmur or abnormal heart position at the height of expiration with the bell of the
sounds is by comparing the auscultatory findings of stethoscope. The auscultatory findings of supine position
the pt with yours. Put your stethpscope on your heart are accentuated in left lateral position as the heart
& on pt’s heart alternatively & compare the findings. moves closer to the anterior chest wall & at the height
of expiration as left sided events are more pronounced
>START AUSCULTATION FIRST OVER MITRAL during expiration.
AREA, THEN IN THE PULMONARY AREA, THEN IN
AORTIC AREA, THEN IN TRICUSPID AREA & THEN >While auscultating, place your left thumb over the rt
IN LT 3RD & 4TH INTERCOSTAL SPACES. carotid artery at the level of the upper border of the
>BELL OF THE STETHOSCOPE is used to listen lowpitched thyroid cartilage to distinguish S1 which is synchronous
with the carotid pulsation from S2 which is felt after
sounds like-Murmur of MS, TS, S3 & S4, Fetal heart
carotid pulsation.
sounds, Venous hum etc. During the use of the bell, it
should be placed very lightly over the skin. >In the presence of mitral systolic (pansystolic)
>1.Bell is lightly pressed (just enough to produce an air murmur, auscultate the lt axilla & inferior angle of
scapula for radiation of MR (=MI) murmur.
seal with its full rim) to the skin to listen LOW PITCHED
SOUND. 2.Diaphragm is firmly applied to the skin to
listen HIGH PITCHED SOUND. 1.HEART SOUND
>Low-pitched sounds like murmurs of MS & TS are best
> DESCRIBE ONLY FIRST HEART SOUND in mitral area &
auscultated by the bell of the stethoscope while all other
not other heart sounds.
murmurs are best auscultated by the diaphragm of the
stethoscope. >First heart sound (S1)-Auscultated with the diaphragm
>3rd (S3) & 4th (S4) heart sounds are best heard with • Intensity-Normally audible/ Loud & snapping (in
MS)/ Distant (in Pericardial effusion)
the pt turned to the left side & auscultated with the bell
• Rhythm-Regular/ Irregular
of the stethoscope.
>Heart sounds are distant means the intensity of heart
>Conventional abbreviations used in cardiac auscultation
sounds is decreased on auscultation i.e heart sounds
are-
become muffled e.g pericardial effusion.
• S1-First heart sound-Produced by closure of
mitral & tricuspid valves. >Tell that heart sounds are distant if sounds are
diminished in intensity.
• S2-Second heart sound-Produced by closure of >Do not tell S1 to the examiner. Tell first heart sound.
aortic & pulmonary valves. Similarly do not tell the other abbreviations to the
examiner.
• A2-Aortic component of second heart sound >ALWAYS MENTION THE HEART SOUNDS FIRST IN
(S2)-Produced by closure of aortic valves. CARDIAC AUSCULTATION.
• P2-Pulmonary component of second heart 2.MURMUR

sound (S2)-Produced by closure of pulmonary
valves. *Tell only if present.
Murmurs originating from the rt side of the heart
• S3-Third heart sound increase in the intensity during inspiration owing to
increase in the stroke output of the rt ventricle.
• S4-Fourth heart sound Conversely, murmurs arising from the lt side of the
heart are accentuated during expiration.
• OS-Opening snap
A.TIMING
• EC-Ejection click
a.SYSTOLIC
A.MITRAL AREA (=CARDIAC APEX)
PANSYSTOLIC (=HOLOSYSTOLIC)
(Half inch in diameter with center at the apex of the
heart) Starts immediately with S1 & continue through to the
>By saying cardiac apex or apex of the heart, we S2& ends after S2. These murmurs always have a
normally mean MITRAL AREA. So, mitral area can be uniform intensity, e.g MR
assumed to be synonymous with the apex of the
heart or cardiac apex or simply apex. LATE-SYSTOLIC
POSITION OF THE PATIENT e.g Hypertrophic obstructive cardiomyopathy
Before auscultation, localize the apex beat by palpation b.DIASTOLIC

with the pt in supine position. If the apex beat could not
be localized properly, auscultate the area below the lt MID-DIASTOLIC
nipple. At first, you auscultate the pt in supine (i.e
dorsal decubitus) position with the diaphragm of the
24
Heard relatively late after the S2 & continue for a VI thrill. Heard with the stethoscope removed
variable period during mid-diastole e.g MS, Carey from the contact with the chest i.e
coombs murmur, Apical middiastolic murmur of AR stethoscope is kept close to the chest wall but
(Austin Flint murmur) not in contact with the chest wall.
AUSTIN FLINT MURMUR ! FOR SIMPLICITY, ONE CAN REMEMBER THAT A MURMUR
OF GRADE-III IS NOT ASSOCIATED WITH A THRILL
It is a soft, lowpitched, rumbling, middiastolic murmur WHILE A MURMUR OF GRAD IV IS ASSOCIATED WITH A
heard at the mitral area. It is associated with severe THRILL. GRADE V MURMUR IS VERY SEVERE & IS
aortic regurgitation. It is probably produced by the ASSOCIATED WITH VISIBLE PULSATION. FUNCTIONAL
MURMURS ARE NEVER ASSOCIATED WITH THRILLS. SO,
diastolic displacement of the anterior leaflet of the
IF A MURMUR IS ONLY HEARD BUT IS NOT ASSOCIATED
mitral valve by the aortic regurgitation jet leading to WITH A THRILL, THEN IT IS GRADE III. IF A MURMUR IS
partial closure of the anterior mitral leaflet & therby HEARD & IS ASSOCIATED WITH A THRILL, THEN IT IS
rendering the mitral valve functionally stenotic. But it GRADE IV
does not appear to be associated with hemodynamically
significant mitral obstruction and in contrast to the >Typical description-Murmur is III/VI in intensity.
diastolic murmur of the MS, it is not accompanied by an
opening snap or loud S1. D.RADIATION TO
CAREY-COOMBS MURMUR -Carotids in neck/ Lt axilla/ Back of the chest/ Lt
sternal edge/ Upper right sternal edge
It is a soft middiastolic murmur may sometimes be *Radiation is useful in differentiating systolic murmurs.
heard in acute rheumatic fever due to inflammation of
the mitral valve cusps with nodules on the mitral valve E.POSITION
leaflets or excessive lt atrial blood flow as a
consequence of mitral regurgitation. -Heard best in-Dorsal decubitus position/ Lt lateral
position/ Sitting & leaning forward position
B.QUALITY=CHARACTER
F.HEARD BEST WITH
-Soft/ Soft & blowing/ Rough/ Loud & rough
-Bell/ Diaphragm of the stethoscope
>Regurgitant murmurs produced by backward leakage
through a closed but incompetent valve are soft & G.HEARD BEST IN
blowing in character. PANSYSTOLIC MURMUR IS
ALWAYS SOFT & BLOWING IN CHARACTER. -Full expiration/ Full inspiration
>OBSTRUCTIVE MURMURS produced due to obstruction TYPICAL DESCRIPTION OF MURMUR

to forward flow of blood through the narrowed valves
are usually ROUGH in character. A harsh midsy-stolic ejection murmur of grade IV/VI
with radiation towards carotids is heard. The murmur is
>If you can not recognize the quality of murmur in
best audible in full expiration with the pt sitting &
exam, don’t worry. First you diagnose the case & then
leaning forward & with the diaphragm of the
retrogradely tell the quality of murmur found in that
stethoscope.
disease even if you can not appreciate that in the given
pt.
3.ADDED SOUND
C.LOUDNESS GRADE a.OPENING SNAP (OS)
-I/VI, II/VI, III/VI, IV/VI, V/VI, VI/VI
-Present/ Absent
LOUDNESS GRADE
>It is heard just after S2 i.e in the early part of the
GRADE CHARACTERISTICS diastole (between 0.04s to 0.12s after A2) & is
Heard with stethoscope with utmost immediately followed by mid-diastolic murmur of MS. It
I concentration (in a quiet room) i.e very faint is sharp & high pitched & is best heard in standing
or soft. position after expiration with the diaphragm of the
stethoscope at lower left sternal border. It is loudest in
II Easily heard, not so loud & no thrill (i.e soft)
between the apex beat & the lt sternal border & may be
III Moderately loud, no thrill & heard with lightly
the loudest sound in the cardiac cycle. The sound
placed stethoscope
radiates well to the base of the heart.
IV Loud with thrill & heard even with the edge of
>It is usually due to stenosis of an atrioventricular
the stethoscope touching the chest
valve, mostly mitral valve, but can be heard ion
Very loud & with thrill & heard with
tricuspid valve stenosis.
V stethoscope half inch away from chest over
>It is almost always heard in all cases of pure MS, but is
a wide area
absent or masked in severe sclerosis & calcification of
Heard without stethoscope, associated with
25
the mitral valve, associated severe MR, severe degree of " Low pitched, presystolic (i.e heard before S1) sound
pulmonary hypertension (PHTN) & RVH & in the produced in the ventricle late in the diastole during
presence of significant AR. 2nd rapid filling phase. It is associated with effective
>Produced due to elevated left atrial pressure causing atrial contraction. It occurs when there is increased
forceful opening of the thickened & stiff mitral valve resistance to ventricular filling due to diminished
leaflets in MS. ventricular compliance.
>The A2-OS interval is inversely related to the height of " S4 is caused by inrush of blood into the ventricles
the mean left atrial pressure. when the atria contract & hence it is also called as the
Atrial Heart Sound. It is heard during the ventricular
filling phase of the cardiac cycle (Presystolic sound).
b.EJECTION CLICK (EC)
" S4 is more commonly pathological & occurs when
-Present/ Absent vigorous atrial contraction late in the diastole is
required to augment filling of a hypertrophied, non-
>Sharp & high-pitched clicking sound heard immediately copliant ventricle (e.g hypertension, aortic stenosis,
hypertrophic cardiomyopathy)
after S1 i.e in early part of systole & is immediately
" It is low pitched (frequency usually 20 Hz or less). It
followed by the ejection murmur. It is loudest in
is not audible to the unaided ear & is almost never
expiration & is best audible in aortic area (Aortic
heard even with a stethoscope because of its
Ejection Click) and pulmonary area (Pulmonary Ejection
weakness and low frequency. It becomes audible
Click).
when diminished ventricular compliance increases the
>Aortic Ejection Click does not change with respiration &
resistance to normal filling.
can be heard all over the precordium, while Pulmonary " It is best heard (Loudest) at the apex with the bell of
Ejection Click increases in intensity with expiration & is the stethoscope when the pt is in left lateral position.
localized to the pulmonary area. It is accentuated by mild isotonic or isometric exercise
>Pulmonary Ejection Click is the only rt sided event in the supine position.
which is best heard in expiration & is not accentuated in >Apex means left ventricular apex. There is no right
inspiration. ventricular apex.
>The clicks are due to sudden opening of the aortic or *Just know it. Don’t tell in exam even if you detect it.
pulmonary semilunar valves in conditions where this Tell only when asked.
opening is delayed like AS,PS, Hypertension. Its
presence indicates that stenosis is at the valvular level & f.GALLOP RHYTHM
the stsnosis i.e AS or PS is of milder degree.
-Present/ Absent
c.MIDSYSTOLIC CLICK
(=NON-EJECTION CLICK) >If S3 or S4 is heard along with S1 & S2, it is called
TRIPPLE RHYTHM. Tripple rhythm plus tachycardia is
Heard in the systole, but later than systolic ejection called GALLOP RHYTHM because of its resemblance with
sounds. That is why it is called as midsystolic clik. Heard the candence produced during galloping of horses.
in mitral valve prolapse. Presence of gallop rhythm is a cardinal sign of lt vent-
ricular failure (LVF).
*Just know it. Don’t tell in exam even if you detect it. >S3 or S4 are best heard at the apex with the bell of the
Tell only when asked. stethoscope placed lightly. Sometimes they are best
heard with the pt turned to lt lateral position. Often they
d.THIRD HEARD SOUND (S3) are better felt than heard. They are low pitched sounds.
Left-sided S3 (LVF) is best audible at the apex during
-Present/ Absent expiration while the right-sided S3 (RVF) is best heard
at the lower lt sternal border during inspiration.
Low pitched sound produced in the ventricle 0.14 to >S3 Gallop=Protodiastolic Gallop
0.16 seconds after A2 in the early part of the diastole at
*Just know it. Don’t tell in exam even if you detect it.
the termination of rapid filing phase. S3 occurs due to
Tell only when asked.
increase in the rate or increase in the volume of
ventricular filling. It is best heard with the bell of the
stethoscope at the cardiac apex. S3 & S4 are caused by
g.PERICARDIAL KNOCK
abrupt tensing of the ventricular walls following rapid
-Present/ Absent
diastolic filling. Rapid filling occurs early in the diastole
(S3) following atrioventricular valve opening & again
It is the S3 that occurs earlier i.e 0.01s to 0.12 seconds
later in the diastole (S4) due to atrial contraction.
after A2 & is higher pitched than normal. It is due to
*Just know it. Don’t tell in exam even if you detect it.
sudden deceleration of ventricular filling because of
restrictive effect of the adherent pericardium. It often
occurs in constrictive pericarditis.
e.FOURTH HEART SOUND (S4) *Just know it. Don’t tell in exam even if you detect it.
-Present/ Absent
h.PERICARDIAL FRICTION RUB

26
(=PERICARDIAL RUB) inspiration). The auscultatory findings are heard better
i.e. accentuated when the auscultation is carried out
-Present/ Absent with the pt sitting & leaning forward because, in this
position, the base of the heart moves forward i.e. close
*Just know it. Don’t tell in exam even if you detect it. to sternum.
1.HEART SOUND
i.VENOUS HUMS
-Pulmonary component (P2) of the second heart sound
-Present/ Absent (S2) is-Normally audible/ Loud/ Distant (i.e feeble or
muffled)
A continuous venous hum at the base of the heart
reflects hyperkinetic jugular venous flow. It is SPLITTING OF THE HEART SOUNDS
particularly common in infants & usually disappears on
lying flat. " Normally we hear two heart sounds i.e S1 & S2
*Just know it. Don’t tell in exam even if you detect it. " S1 representing both mitral & tricuspid valve closure
Tell only when asked. is usually single i.e usually, mitral valve closure &
tricuspid valve closure occurs simultaneously without
j.TUMOR PLOP any gap, and therefore we hear a single first heart
sound. We never hear mitral & tricuspid valve closure
-Present/ Absent sounds separately.
" S2 representing both aortic & pulmonary valve closure
Low pitched sound audible during early or mid-diastole is usually not single i.e usually, aortic valve closure
& is produced due to the tumor abruptly stopping as it (A2) & pulmonary valve closure (P2) do not occur
strikes the ventricular wall. Heard in atrial myxoma. simultaneously i.e there is a gap between A2 & P2.
*Just know it. Don’t tell in exam even if you detect it. This is called splitting of heart sound. Normally A2 is
Tell only when asked. first heard & then P2 is heard except in case of
reversed splitting in which P2 is first heard &
SEQUENCE OF SOUNDS HEARD IN CARDIAC then A2 is heard.
AUSCULTATION:-
S4#S1#EC#S2#OS#PK#S3#S4. " PHYSIOLOGICAL SPLITTING
During inspiration, increased venous return to the right
This means EC is heard after we hear S1 but before we heart delays right ventricular emptying in comparision
hear S2 and OS, PK, S3 & S4 is heard after we hear S2 to left ventricle leading to closure of aortic valve earlier
but before we hear S1. EC means ejection click, OS than pulmonary valve. But during expiration, no such
means opening snap & PK means pulmonary knock. thins happen and therefore there is no splitting & we
hear a single S2. This is called physiologica splitting.
" All added sounds are heard in diastole except ejection
click & mid-systolic click which are heard in systole. 2.MURMUR
" Sounds produced when the valve closes- Opening
snap & Ejection click A.TIMING
" Sounds produced when the valve opens- S1 & S2
" Sounds produced with open valves due to turbulence- a.SYSTOLIC
S3 & S4
" Sound heard shortly after S1- Ejection click EJECTION SYSTOLIC (=MID-SYSTOLIC)
" Sound heard shortly before S1- S4
" Sound heard shortly after S2 – Opening snap/ Starts shortly after S1 & disappears before S2, loudest
Pericardial knock/ Tumor plop/ S3 in the aortic area (with radiation to the neck) or in the
" Sound heard midway between S1 & S2 – Mid-systolic pulmonary area & best heard with the diaphragm of the
click stethoscope while the pt sits forward e.g PS, Fallot’s
" Opening snap due to mitral stenosis occurs earlier tetralogy. Ejection systolic murmurs are always mid-
than opening snap due to tricuspid stenosis. systolic murmurs & are never early systolic murmurs.
" Heart sounds are so named because they occur in that
sequence i.e S1 is heard followed by S2, followed by b.DIASTOLIC
S3 & followed by S4 & then S1 starts again.
EARLY DIASTOLIC
B.PULMONARY AREA High pitched & start immediately after S2 fading away in
mid-diastole. Best heard with diaphragm of the
(Half inch in diameter with center in the left 2nd ICS
stethoscope while the pt leans forward e.g PR
close to sternum)
c.CONTINUOUS (=SYSTOLO-DIASTOLIC)
POSITION OF THE Pt -Pt lies supine. Auscultate with the
diaphragm of stethoscope at the height of inspiration
Heard during systole & diastole. Persists through the
(as right sided events are more pronounced during
end of systole & beginning of diastole. Are uninterrupted
27
by valve closure & OBLITERATES THE S2. pulmonary area & best heard with the diaphragm of the
Obliteration of S2 is a must to characterize the stethoscope while the pt leans forward e.g AS,
murmur as continuous murmur e.g PDA Hypertrophic Cardiomyopathy (HCM) & Bicuspid aortic
value (Midsystolic). Ejection systolic murmurs are
B.QUALITY=CHARACTER always mid-systolic murmurs & are never early systolic
murmurs.
-Soft/ Soft & blowing/ Rough/ Loud & rough
b.DIASTOLIC
C.LOUDNESS GRADE
EARLY DIASTOLIC
High pitched & start immediately after S2 fading away in
D.RADIATION TO mid-diastole. Best heard with diaphragm of the
stethoscope while the pt leans forward e.g AR, Graham
-Carotids in neck/ Lt axilla/ Back of the chest/ Lt sternal Steell Murmur
edge/ Upper rt sternal edge
*Radiation is useful in differentiating systolic murmurs. GRAHAM STEELL MURMUR
F.HEARD BEST WITH The Graham Steell murmur of pulmonary regurgitation

is a high-pitched, early diastolic, decrescendo blowing
-Bell/ Diaphragm of the stethoscope murmurheard along the lt sternal border which results
from the dilatation of the pulmonary valve ring in mitral
G.HEARD BEST IN valve disease & severe pulmonary hypertension. This
murmur may be indistinguishable from the more
-Full expiration/ Full inspiration common murmur produced by aortic regurgitation.
E.POSITION c.CONTINUOUS (=SYSTOLO-DIASTOLIC)
-Heard best in-Dorsal decubitus position/ Lt lateral Heard during systole & diastole. Persists through the
position/ Sitting & leaning forward position end of systole & beginning of diastole. Are uninterrupted
by valve closure & OBLITERATES THE S2.
3.ADDED SOUND Obliteration of S2 is a must to characterize the
murmur as continuous murmur e.g PDA
C.AORTIC AREA B.QUALITY=CHARACTER
(Half inch in diameter with center in the rt 2nd ICS close
to sternum) -Soft/ Soft & blowing/ Rough/ Loud & rough
POSITION OF THE Pt-Pt lies supine. Auscultate with the C.LOUDNESS GRADE
diaphragm of stethoscope at the height of expiration (as
left sided events are more pronounced during -I/VI, II/VI, III/VI, IV/VI, V/VI, VI/VI
expiration). The auscultatory findings are heard better
i.e. accentuated when the auscultation is carried out D.RADIATION TO
with the pt sitting & leaning forward because, in this
-Carotids in neck/ Lt Axilla/ Back of the chest/ Lt sternal
position, the base of the heart moves forward i.e. close
edge/ Upper rt sternal edge
to sternum. Confirm the radiation of murmur to carotids
*Radiation is useful in differentiating systolic murmurs.
(AS) or towards the neoaortic area (AR).
1.HEART SOUND
F.HEARD BEST WITH
-Bell/ Diaphragm of the stethoscope

-Aortic component (A2) of the second heart sound (S2)
is-Normally audible/ Loud/ Distant (i.e feeble or
G.HEARD BEST IN-Full expiration/ Full inspiration
muffled)
E.POSITION
2.MURMUR
-Heard best in-Dorsal decubitus position/ Lt lateral
A.TIMING position/ Sitting & leaning forward position
a.SYSTOLIC 3.ADDED SOUND
EJECTION SYSTOLIC (=MID-SYSTOLIC) D.TRICUSPID AREA

Starts well after S1 & disappears before S2, loudest in (Half inch in diameter with center in the Lt 5th ICS
the aortic area (with radiation to the neck) or in the close to sternum)

28
POSITION OF THE Pt -Pt lies supine. Auscultate with the with the diaphragm of the stethoscope. Aortic
diaphragm of stethoscope at the height of inspiration. regurgitation murmur best heard in this region.
1.HEART SOUND MURMURS HEARD IN NEOAORTIC AREA
2.MURMUR 1.SYSTOLIC
A.TIMING a.EJECTION SYSTOLIC (=MID-SYSTOLIC)
1.SYSTOLIC Starts well after S1 & disappear before S2, loudest in

the aortic area (with radiation to the neck) or in the
a.PANSYSTOLIC (=HOLOSYSTOLIC) pulmonary area & best heard with the diaphragm of the
stethoscope while the pt sits forward e.g ASD. Ejection
Starts immediately with S1 & continue through to the systolic murmurs are always mid-systolic murmurs &
S2& ends after S2. These murmurs always have a are never early systolic murmurs.
uniform intensity, e.g TR
>ASD murmur is heard in pulmonary area & neoaortic
b.DELAYED DIASTOLIC area.
e.g ASD b.PANSYSTOLIC (=HOLOSYSTOLIC)
B.QUALITY=CHARACTER Starts immediately with S1 & continue through to the

S2& ends after S2. These murmurs always have a
-Soft/ Soft & blowing/ Rough/ Loud & rough uniform intensity, e.g VSD. VSD does not produce
continuous murmur.
C.LOUDNESS GRADE
2.DIASTOLIC
a.EARLY DIASTOLIC
D.RADIATION TO
High pitched & start immediately after S2 fading away in
-Carotids in neck/ Lt axilla/ Back of the chest/Lt sternal mid-diastole. Best heard with diaphragm of the
edge/ Upper rt sternal edge stethoscope while the pt leans forward e.g AR
*Radiation is useful in differentiating systolic murmurs.
MURMURS HEARD ALONG LEFT STERNAL BORDER
F.HEARD BEST WITH
1.Murmur of functional TR in severe pulmonary
-Bell/ Diaphragm of the stethoscope hypertension in MS.
2.Graham-Steel murmur of PR.
G.HEARD BEST IN 3.Rt sided S3 (Right ventricular gallop) is heard at the
lower lt sternal border.
-Full expiration/ Full inspiration
F.CAROTID BRUIT
E.POSITION
-Heard/ Not heard
-Heard best in-Dorsal decubitus position/ Lt lateral
position/ Sitting & leaning forward position >Put your stethoscope over the carotid artery and listen
for any murmur.
3.ADDED SOUND
G.PERICARDIAL FRICTION RUB
>Typical description-No murmurs & no added sounds
are heard.
-Present/Absent
*Tell only if present.
E.LEFT 3rd& 4th PARASTERNALREGION
PERICARDIAL FRICTION RUB
NEOAORTIC AREA
High pitched, superficial, SCRATCHING, inconstant, to-
-Murmur heard/ Murmur not heard and-fro, leathery sound audible during the any part of
*Tell only if present. the cardiac cycle. Best heard at the left side of the lower
sternum using the diaphragm of the stethoscope with
• NEOAORTIC AREA-Lt 3rd ICS close to parasternal the Pt. breathing out in sitting position. Intensity of the
line. This area is auscultated with the pt sitting & sound increases when the Pt. sits & leans forward & also
leaning forward position at the height of expiration by pressing the diaphragm of the stethoscope (pleural

29
RESPIRATORY SYSTEM
friction rub does not increase in intensity by pressing
the diaphragm of the stethoscope). Sound continues
EXAMINATION
even after holding the breath (in contrast to pleural
friction rub which disappears after holding the breath) &
may be associated with chest pain & usually there is no
transmission (i.e localized). The hallmark of diagnosis of POSITIONING THE PATIENT BEFORE
pericardititis is pericardial rub. EXAMINING THE RESPIRATORY SYSTEM
>PLEUROPERICARDIAL RUB-It is due to rubbing of the Respiratory system is usually examined in standing
pleura with the pericardium.It is confused with the position. It is examined in sitting position if the patient
pericardial rub. is unable to stand. While examining the anterior (front)
>Describing normal CVS-First & second heart sounds chest wall, ask the pt to sit or stand erect with both the
are normally audible,No murmur & No added sounds. upper limbs hanging on the sides of the body laterally.
While examining the lateral chest wall, ask the pt to
F.OTHER raise both his upper limbs, flex them at the elbow &
place both his palms over the head, with one palm
1.PISTOL SHOT SOUND (=TRAUBE’S SIGN) above the other. This will expose the lateral chest wall
for examination. While examining the posterior (back)
Booming sound produced after lightly pressing the bell chest wall, ask the pt to flex both the upper limbs at the
of the stethoscope over the femoral artery. elbow, cross the forearms & then place the crossed
forearms on the anterior (front) chest wall. This will
2.DUROZIEZ’S MURMURS separate the two scapulae & help in the examination of
the back.
Place the diaphragm of your stethoscope over the
femoral artery just below the inguinal ligament. >Inspection of back in respiratory system &
Press(by tilting the diaphragm) the upper margin (below cardiovascular system is always done in STANDING
the inguinal ligament) of the diaphragm of the position if the condition of the pt permits to avoid undue
stethoscope to hear a systolic murmur in case of aortic obliquity.
regurgitation (AR) which has no special name.If you
press the lower margin(away from the inguinal AREAS OF THE CHEST WALL
ligament) of the diaphragm of the stetho-scope,the
diastolic murmur thus heard is called Duroziez’s a.ANTERIOR (FRONT) CHEST WALL
murmur.Duroziez’s murmur is heard before the Pistol-
shot sound. From above downwards, the areas are
1.SUPRACLAVICULAR
3.DANCING CAROTID (=CORRIGAN’S SIGN) 2.INFRACLAVICULAR
3.MAMMARY
It is seen in sitting position.It is the exaggerated arterial
pulsation in the carotid artery in the neck. There is no inframammary area.
4.QUINCKE’S SIGN (CAPILLARY PULSATION) b.LATERAL CHEST WALL
• When pressure is applied to the fingertips or From above downwards, the areas are
nails,there is alternate flushing and pallor of the nail 1.AXILLARY
bed OR 2.INFRAAXILLARY
• When a glass slide is on the everted lower lip(inner
aspect of lower lip),it produces alternate redness and There is no midaxillary area.
blanching OR you can press the upper part of the
c.POSTERIOR (BACK) CHEST WALL
tongue with a glass slide similarly.
From above downwards, the areas are
5.COLLAPSING PULSE
1.SUPRASCAPULAR
(=WATER HAMMER PULSE=CORRIGAN’S PULSE)
2.INTERSCAPULAR (UPPER & LOWER)
3.INFRASCAPULAR
6.LOCOMOTOR BRACHIALIS
There is no middle interscapular area.
7.CORRIGAN’S PULSE
8.De MUSSET’S SIGN I.INSPECTION

To-and-fro head nodding synchronous with the carotid 1.POSITION OF TRACHEA
pulsation.
-Central/ Shifted to rt/ Shifted to lt
>Typical description in a normal case-Trachea appears
to be central.

30
2.SHAPE OF THE CHEST bending of the vertebral column with its convexity
posteriorly.
-Elliptical/ Barrel shaped/ Pigeon chest (=Pectus >Normal chest is bilaterally symmetrical.
craniatum)/ Funnel shaped chest (=Pectus excavatum)
4.LOCATION OF APICAL IMPULSE
To know the shape of the chest, you have to measure
the transverse as well as anteroposterior diameter of -5th ICS 1.5 cm (½ inch) medial to MCL/ Displaced-
the chest. To measure the transverse diameter of the Inside or outside the MCL
chest, ask the pt to raise both of his hands & then stand >In inspection, you tell that apical impulse is not visible.
in contact with the wall (of the examination room). Then
place a cardboard on the lateral side of the opposite 5.MOVEMENTS OF THE CHEST WALL WITH
chest wall facing the wall (of the examination room). RESPIRATION
Then measure the distance between the wall & the
cardboard which will give you the transverse diameter of • Both the sides of the chest move simultaneously &
the chest. Similarly, for measuring the anteroposterior symmetrically
diameter of the chest wall, ask the pt to stand erect • Restriction of movement of any part
with his back in close apposition with the wall (of the
examination room). Then place a cardboard over the 6.FULLNESS/ DEPRESSION OF CHEST
anterior chest wall and measure the distance between
the cardboard and the wall (of the examination room) • Localised-Rt/ Lt
which will give you the anteroposterior diameter of the • Generalised-Rt/ Lt
chest wall.
7.PROMINENT VEINS OVER THE CHEST WALL
DESCRIPTION OF THE NORMAL CHEST
-Absent/ Present-Pulsatile/ Nonpulsatile
Elliptical in crossection i.e transverse to anteroposterior >Position of mediastinum is determined by noting the
diameter ratio is 7:5, bilaterally symmetrical and trachea & apex beat position i.e whether these two are
without undue elevation or depression. Both the sides of in central position or shifted to one side.
the chest move simultaneously & symmetrically.
Subcostal angle is acute i.e < 900 (males having a TRAIL’S SIGN (=STERNOMASTOID SIGN)
narrower angle than females).
>In barrel shaped chest, the anteroposterior diameter is Undue prominence of sternal head of the stenomastoid
more than the transverse diameter of the chest. muscle on that side towards which the trachea is
deviated.
3.SYMMETRY OF THE CHEST
8.DROOPING OF SHOULDER
• Bilaterally symmetrical
• Kyphosis/ Scoliosis/ Precordial bulging/ Bulging of -Present/Absent
ICS/ Flattening of chest wall
>Drooping of the shoulder is examined in standing
>Note the distance of medial borders of scapulae from position of the pt at a distance of 5 METER (If you
midline on the both sides which is useful to assess any observe very close to the pt, you will miss finer
asymmetry of the chest. abnormalities). Look from backside & observe for-
>Inspection for the shape & movement of the chest-For • Lower angle of scapula on the diseased side is at a
this the pt should stand absolutely straight. Sitting lower level than on the healthy side.
means the pt will sit on a stool. • Area between the spinous processes of vertebrae &
>There is bulging of ICS in pleural effusion or empyema medial border of scapula is increased on diseased side
& pericardial effusion. than on the healthy side.
• Crowding of the ribs on the diseased side.
METHOD TO DETECT SCOLIOSIS >From the above three findings, you can conclude that
there is drooping of shoulder which signifies apical
The pt will stand straight with fully exposed chest & the fibrosis or collapse of lung. Tell drooping of the shoulder
observer looks for scoliosis from his back. It is observed is present only when above three findings are present.
whether the convexity is present in lt or rt side.
Afterwards, it may be corroborated by palpation of the
spine. Scoliosis means lateral bending of the spinal cord. 9.CROWDING OF RIBS
METHOD TO DETECT KYPHOSIS -Present/ Absent
The observer inspect the back from the sides in profile >See from backside & frontside
i.e a tangential view from both the sides are necessary.
The pt will stand straight with fully exposed chest. In 10.WIDENING OF INTERCOSTAL SPACES
kyphosis, there is increase in the anteroposterior
diameter of the chest. Kyphosis means backward - Present/ Absent

31
>Place index finger firmly into the suprasternal notch &
11.SKIN OVER THE CHEST locate the tracheal rings in relation to sternum.
>Find out the space between the anterior border of
-Puncture mark/ Scar mark/ Discharging sinus sternomastoid & trachea. In deviation, the space
appears to be narrow on the side towards which the
12.RESPIRATORY MOVEMENT trachea is deviated.
A.RHYTHM
2.LOCATION OF APEX BEAT
• 1.Regular th
-5 ICS ½ inch medial to MCL/ Displaced-Inside or
• Irregularly irregular (=Biot’s breathing)
outside the MCL
• Regularly irregular (=Cheyne-Stokes respiration)
> SHIFTING OF MEDIASTINUM IS DETERMINED FROM
• Miscellaneous-Stertorous breathing
THE POSITION OF TRACHEA & LOCATION OF APEX
BEAT.
B.TYPE
3.MOVEMENTS OF CHEST WALL
-Abdominothoracic/ Thoracoabdominal/ Exclusively
abdominal/ Exclusively thoracic/ Paradoxical respiration/
Pursed-lip breathing - Bilaterally symmetrical
- Restricted in-Rt side/ Lt side
C.DEPTH >One has to assess whether both sides of the chest are
moving simultaneously & symmetrically, or not. This is
-Normal/ Shallow/ Deep/ Kussmaul’s breathing conventionally done at three places-
D.INDRAWING OF A.FRONT
• Intercostal spaces (Intercostal suction)-Present/Absent

First ask the pt to exhale completely. Anteriorly, place
• Subcostal spaces-Present/ Absent the curve formed by your ulnar border of thumb & radial
• Suprasternal fossa (or space)-Present/ Absent border of index finger of the two hands on the chest wall
• Supraclavicular fossa-Present/ Absent just below the nipple while two thumbtips apposing
eachother in midline with a fold of skin between the
>HOOVER’S SIGN-Paradoxical inward movement of rib thumbtips. Ask the pt to take deep breath & observe the
cage with respiration. movements of the thumbtips away from the midline.
E.ACCESSORY MUSCLES OF RESPIRATION B.BACK

(Sternomastoid, scalenii & trapezii)
a.INTERSCAPULAR AREA
-Used/ Not used
First stand behind the pt. Then ask the pt to exhale
BIOT’S BREATHING
completely. Place the palms vertically side by side in the
interscapular region. Note the elevation or lifting of the
This type is sometimes slow & sometimes rapid & is
palms with inspiration.
found in meningitis, Children etc.
CHEYNE-STOKES BREATHING b.INFRASCAPULAR REGION
STERTOROUS BREATHING Same method, as used for the front of the chest. Note
the separation of thumbtips with inspiration.
II.PALPATION C.APEX
1.POSITION OF TRACHEA
1.PREFERRED METHOD
- Central/ Shifted to rt/ Shifted to lt
First ask the pt to exhale completely. Then standing
>Pt. is in standing (most preferable) or sitting position behind the pt, place your medial 4 finger & palm over
the shoulder in such a way that the 2 thumbs meet in
with arms placed symmetrically on two sides & chin held
the midline in obliquely & downward direction. Ask the
in midline (TRACHEA SHOULD NOT BE EXAMINED IN
LYING DOWN POSITION UNLESS THE PATIENT IS VERY pt to take deep breath in & you observe the separation
ILL). Stand in front of the pt & place your index & ring of thumbtips from the midline.
finger of the rt hand on sternoclavicular joints of either
2.ALTERNATIVE METHOD
side. The middle finger is placed on the cricoid cartilage
(lies below thyroid cartilage) & gently slide it down over
First ask the pt to exhale completely. Then standing
the tracheal rings upto suprasternal notch. The trachea
behind the Ppt, place the two thumbs at the nape (back)
is normally felt in the midline & in deviation, finger will
of the neck with their radial border in apposition in the
slide down along the other side of the trachea.
midline at the level of the vertebral prominence (spinous
32
process of 7th cervical vertebra) & the palms resting on depth & intensity of voice remaining same). Place the
the shoulders. Ask the pt to take deep breath & observe entire hypothenar eminence of your palm upto the base
the elevation or lifting of the thumbs. The movement of of the little finger (the rest part of the palm should not
the apex may be examined from the front in a pt who is touch the chest wall) horizontally over the ICS. Feel the
unable to sit:-pt will lie down & palms will be placed vocal fremitus, comparing the corresponding areas on
over the clavicles from the front. both sides alternatively. First test in the normal side &
then test in the diseased side. Always use the same
>After the clinical assessment of the movement of the hand ( rt Hand) for examining both sides. Avoid the
chest, always measure the expansion with a measuring area of cardiac dullness on the lt side by placing the
tape. hand a bit laterally. Start from above downwards in
>Movement of the chest is examined only anteriorly & front & back of the chest. Describe the vocal fremitus
posteriorly, but is never examined laterally. with respect to different areas of the chest wall i.e in
which area it is increased or decreased. Confirm the
4.EXPANSION OF CHEST WALL altered (increased or decreased) vocal fremitus by
auscultating for increased vocal resonance, i.e first
1.PREFERRED METHOD confirm that the vocal resonance is increased or
decreased & then only tell that vocal fremitus is
Hold the tape at the nipple level with both the hands in increased or decreased.
such a way that your hands do not touch the chest wall
by crossing the tape in the midline. Then ask the pt to TYPICAL DESCRIPTION OF VOCAL FREMITUS
exhale & then take deep breath in & hold it. At the end Vocal fremitus is decreased in infraclavicular area.
of the exhalation, note the markings on the tape. When
the pt starts taking deep breath, you release the tape >VOCAL FREMITUS, PERCUSSION & AUSCULTATION OF
from one hand & note the marking at the end of the THE CHEST ARE DONE ALONG MIDCLAVICULAR LINE
inspiration. Find out the chest expansion from initial & ANTERIORLY ,ALONG MIDAXILLARY LINE (UPPER
AXILLA, MID AXILLA & LOWER AXILLA) LATERALLY & IN
final reading of the tape.
BACK-A.UPPER PART-SUPRASCAPULAR AREA, B.MIDDLE
PART-INTERSCAPULAR AREA, C.LOWER PART-
2.ALTERNATIVE METHOD
INFRASCAPULAR AREA ALONG SCAPULAR LINE.
Measured with a measuring tape placed just below the

6.TENDERNESS OF RIBS
nipple with zero mark at the middle of the sternum &
the pt is asked to take breath in & out as deep as
-Absent/ Present-Rt/ Lt
possible. Measure the expansion at both maximum
inspiration & maximum forced expiration & findout the
Palpate over that areas of the chest wall where the pt
difference. In women, breast tissue should be avoided
complains of pain & look for tenderness by looking to
by making the measurements just above or below the
the pt’s face.
breast. It is important that several readings should be
taken as the initial respiratory efforts are often irregular
>Rib pain-Multiple myeloma
than subsequent ones.
>Normal expansion is more than equal to 5 cm (5-8 cm) 7.TENDERNESS OVER ICS
in an adult. Expansion of less than 5 cm is described as
Palpate over the ICS by the tip of your finger.
restricted & expansion of 2cm or less is described as
>Tenderness over ICS is found in empyema thoracis.
grossly restricted.
METHOD TO MEASURE THE EXPANSION HEMITHORAX 8.CROWDING OF RIBS
Place the tape only on one side of the chest at the -Absent/ Present-Right/ Left
nipple level with anterior end of the tape placed on the
midsternal line while posterior end of the tape placed on Stand at back side of the pt & place your palmar surface
the spinous process of vertebra i.e midspinal line. Then of hand over the lateral aspect of the chest with fingers
ask the pt to take deep breath in & hold it. Then find out lying over the intercostal spaces. Press the finger
the expansion of hemithorax from initial & final inwards & move them anteriorly in forward & downward
measurements. In case of FIBROSIS, measure the direction comparing with the other side for crowding of
expansion of hemithorax. the ribs.
>Non-respiratory cause giving rise to poor chest 8.WIDENING OF INTERCOSTAL SPACES

expansion is Ankylosing Spondylitis.
- Absent/Present-Rt/ Lt
5.VOCAL FREMITUS Similar procedure as used for crowding of ribs.
-Equal on both sides / Increased / Reduced
Pt is asked to repeat EK-DO-TEEN/ NINETY NINE/ ONE-

ONE-ONE several times in a constant tone & voice (the

33
III.PERCUSSION >Always percuss from above downwards & compare the
note on the identical site on the opposite side of the
chest.
>VOCAL FREMITUS, PERCUSSION & AUSCULTATION of
the chest are performed along MIDCLAVICULAR LINE
THREE CARDINAL RULES OF PERCUSSION
ANTERIORLY; ALONG MIDAXILLARY LINE (UPPER
AXILLA, MID AXILLA & LOWER AXILLA) LATERALLY & IN
BACK ALONG SCAPULAR LINE -A.UPPER PART- 1.Percuss from resonant to dull area or more resonant
SUPRASCAPULAR AREA, B.MIDDLE PART- to less resonant area.
INTERSCAPULAR AREA, and C.LOWER PART- 2.Pleximeter finger should be placed parallel to the
INFRASCAPULAR AREA. border of the organ to be percussed and the line of
percussion should be perpendicular to that arbitary
>7th ICS is the last ICS along MCL while 11th ICS is border.
the last ICS along scapular line. There is no 12th ICS 3.Heavy percussion for deeply placed viscera & light
along scapular line. percussion for superficial viscera.
>Axilla starts from 4th intercostal space.
>Conventionally percussion is done FORMAT OF PERCUSSION OVER THE CHEST
1.Along mid-clavicular line upto 7th ICS
A.ANTERIORLY ON THE RIGHT SIDE
2.Along mid-axillary line upto 8th ICS i.e 4th to 8th
ICS since the axilla starts from 4th ICS. 1.Conventional percussion
3.Along scapular line upto 11th ICS. 2.Liver dullness
3.Shifting dullness
>Middle finger of the lt hand (PLEXIMETER FINGER) is 4.Coin percussion
applied flatly & firmly on the chest wall over the ICS
while the rest of the fingers are lifted off (NEVER ALLOW B.ANTERIORLY ON THE LEFT SIDE
THE OTHER FINGERS EXCEPT THE PLEXIMETER FINGER
TO TOUCH THE CHEST WALL because to avoid 1.Conventional percussion
dampening of the sound by the other fingers). Then the 2.Cardiac dullness
pleximeter finger is percussed with the middle finger 3.Shifting dullness
(PLEXOR FINGER) of the rt hand once or twice. Strike 4.Coin percussion
the centre of the second phalanx of the pleximeter 5.Traube’s space percussion
finger with the tip of the plexor finger held at an rt angle
(to produce a hammer effect) & with the entire C.BACK
movement coming from the wrist joint. As soon as the
blow is given, the plexor finger is raised immediately (to 1.Tidal percussion.
avold dampening of the vibratory sound thus produced
to prevent error in listening). THE OTHER FINGERS OF >Scapula can be percussed directly with the palmar
THE LEFT HAND SHOULD NOT TOUCH THE CHEST WALL. aspect of the four fingers except thumb.
The intensity & quality of the sound produced & feeling >First percuss the clavicle over the medial one-third just
of resistance imparted to the pleximeter finger should lateral to its expanded medial end, only with the plexor
be observed. Rising dullness (higher level of dullness in finger. During the percussion, stretch the overlying skin
the axilla as compared to front & back) and shifting downwards with the lt thumb so that the percussing
dullness should be looked for when pleural effusion is finger does not slip over the clavicle. It is light
suspected. While percussing, pleximeter finger should percussion. DIRECT PERCUSSION OVER THE CLAVICLE
be placed symmetrically over the corresponding areas of GIVES A DULL NOTE IN CASE OF UPPER LOBE
the chest on either side. While percussing the back, the CONSOLIDATION.
pleximeter finger is placed obliquely downwards & >Map out the areas of impaired resonance by percussing
outwards (with the tip of the pleximeter finger pointing from resonant to dull.
upwards) like the fish bones as the ribs & hence the ICS >Percussion is done and reported in relation to ICS
are so directed i.e ICS are directed obliquely. (while vocal fremitus is reported in relation to different
areas of the chest wall).
SEQUENCE OF PERCUSSION
1.PERCUSSION NOTE
Start percussion from the healthy side. CLAVICLES
SHOULD BE PERCUSSED FIRST BY DIRECT PERCUSSION.
-Normally resonant /Hyperresonant/ Impaired/ Dull/
Then anterior chest wall along MCL, then lateral chest
Stony dull/ Tympanic
wall along the MAL & at last the back along the scapular
line. Lastly, percuss the apex of the lung from the back
>Percussion is done & described in terms of ICS.
of the pt. During the percussion of the lateral chest wall
(i.e axilla) along MAL, pt’s hands are kept over his head. Percussion is never described in relation to the different
While percussing the back, cross the pt’s hands over the areas of the chest wall as done in case of auscultation.
knees (or shoulders) & percuss in a bat’s wing or fish- >TYPICAL DESCRIPTION-THERE IS STONY DULLNESS IN
bone pattern as you did for palpation. MAL FROM 4th ICS DOWNWARDS.
>Typical description in a normal case-Chest is
normally resonant bilaterally.

34
KRONIG’S ISTHMUS 5.TIDAL PERCUSSION
It is a small area (a band of resonance of 5-6 cm width, - On deep inspiration, the previous dullness-Persists/
connecting the lung resonance on the anterior & Disappears
posterior chest on each side) in the apex of the lung
(supraclavicular area) which is bounded medially by the Pt sits with forearms crossed in front of the chest &
neck muscles, laterally by the ipsilateral shoulder joint, hands resting on the shoulders. Ask the pt to exhale.
anteriorly by the clavicle & posteriorly by the trapezius Then percuss the lung on one side posteriorly along the
muscle. Kronig’s isthmus is elicited by the percussion scapular line till you get dullness. Keeping your finger at
over the apex of the lung (performed from the back of the site of dullness, ask the pt to take deep inspiration &
the pt), and the percussion note is normally resonant. hold it. Then percusss again at the site of dullness. If
The area becomes dull on percussion in the presence of the dullness persists, then the dullness is
apical tuberculosis, apical pneumonia & Pancoast’s supradiaphragmatic & if the dullness disappears (i.e
tumor. While percussing this area, the pleximeter finger resonant note is now obtained over the previous site of
should be placed over the supraclavicular fossa dullness), then the dullness is infradiaphragmatic. It is
perpendicular to the clavicle & percuss from medial to so because if the dullness is infradiaphragmatic, then it
lateral side. FIRST PERCUSS THE KRONIG’S ISTHMUS will be displaced downwards with inspiration (since the
WHEN PERCUSSING BACK OF THE CHEST. diaphragm goes down during inspiration) & we will get a
>DULLNESS FOUND DURING PERCUSSION OF LUNG IS resonant note at the previous site of dullness & this
DESCRIBED ACCORDING TO THE ICS. FOR EXAMPLE, resonant note is due to expansion of lung during
THERE IS STONY DULLNESS FROM 3rd ICS TO 7TH ICS inspiration. But if the dullness is supradiaphragmatic
ALONG MCL. then it will not go down with respiration & will persist
there & so the previously obtained dullness persists.
2.CARDIAC DULLNESS Normally, the previously obtained dullness disappears &
there is increase in resonance by 4-6cm during
-Present in lt parasternal region over 3rd to 5th ICS/ inspiration. The previously obtained dullness also
Obliterated (Lost) disappears (i.e the normal increase in resonance
decreases) in UPWARD ENLARGEMENT OF LIVER &
3.HEPATIC DULLNESS CHRONIC BRONCHITIS (infradiaphragmatic dullness).
The previously obtained dullness persists (i.e no
-Starts from 5th ICS in rt MCL/ Displaced upwards/ increase in resonance at all) in BASAL PLEURISY &
Displaced downwards BASAL PNEUMONIA (supradiaphragmatic dullness). Tidal
percussion has little practical value.
4.ELICITATION OF HORIZONTAL FLUID LEVEL
6.SHIFTING DULLNESS
>Done if HYDROPNEUMOTHORAX is suspected.
>In sitting position of the pt, percussion is done from -Present/Absent
above downwards in the front along MCL, lateral chest
wallalong MAL & back along scapular line. During Shifting dullness is performed only when there is an air-
percussion from above downwards, a point of dullness is fluid level as in hydropneumothorax, & large lung
reached in the front, lateral chest wall & back where abscess containing air & fluid etc. Shifting dullness is
markings are given by skin pencil. These three points usually performed by percussing along MAL from above
are joined transversely to get a horizontal line encircling downwards & where a dullness is found, the pleximeter
the affected chest wall. This is the upper horizontal finger is kept there. Then the pt is asked to sleep with
border of fluid level & is classically found in the disease side upward & healthy side downward so
hydropneumothorax . that pleximeter finger remains uppermost (For
>In HYDROPNEUMOTHORAX, the change in the note of example,if rt side is affected, ask the pt to lie in lt
percussion from above downwards is tympanitic lateral position). Then wait for 2-3 minute for
(because of air) to stony dullness which is very much gravitation of fluid & then percuss again. If shifting
distinct in comparision to pleural effusion where the dullness is present (as in hydropneumothorax), then the
change in the note of percussion from above downwards percussion note will become hyperresonant.
is resonant to stony dullness. So the term horizontal
fluid level is classically used in hydropneumothorax. >Test for shifting dullness in the chest to exclude
HYDROPNEUMOTHORAX in all cases of pleural effusion.
>IF YOU ARE GETTING DULLNESS ON PERCUSSION OVER
THE CHEST WALL, THEN YOU HAVE TO DESCRIBE THE 8.TRAUBE’S SPACE PERCUSSION
FOLLOWING TWO THINGS-
1.WHETHER THE DULLNESS IS SUPRADIAPHRAGMATIC -Tympanitic/ Dulll
OR INFRADIAPHRAGMATIC WHICH CAN BE DETECTED BY
TIDAL PERCUSSION.
SURFACE ANATOMY OF THE TRAUBE’S SPACE
2.WHETHER THERE IS ANY SHIFTING OF FLUID WHICH
CAN BE DETECTED BY TESTING FOR SHIFTING
DULLNESS. Draw 2 parallel vertical lines, one from the left 6th
costochondral junction & another from the 9th rib in
MAL. Then connect the 2 lines above from the left 5th
costochondral junction to the 9th rib in anterior MAL &
35
below along the lt costal margin. It forms a semilunar 1.BREATH SOUNDS
space & is tympanic on percussion.
-Absent/ Present
BOUNDARIES OF TRAUBE’S SPACE >If present-
On the rt side-Lt lobe of the liver. On the lt side-Spleen, a.QUALITY

On the above-Lt lung resonance [Lt dome of the
diaphragm & lt lung (6th rib)] & On the below-Lt costal 1.Vesicular
margin. Traube’s space lies below the cardiac dullness. 2.Bronchial- Tubular/ Cavernous/ Amphoric
According to Harrison,the borders of the Traube’s space
are-6th rib superiorly, the lt MAL laterally and the lt b.INTENSITY- Normal/ Diminished/ Increased
costal margin inferiorly.
VESICULAR BREATH SOUND
CONTENT OF THE TRAUBE’S SPACE
Rustling (like dry leaves blown by wind) in character,
Fundus of the stomach containing air. So in a healthy intensity & duration of inspiration is more than
person, percussion of the Traube’s space produces a expiration, no gap between inspiration & expiration.
resonant note. Classical site for hearing vesicular breath sound are
infraclavicular, mammary, infra-axillary & infrascapular.
METHOD OF PERCUSSION OF TRAUBE’S SPACE >NORMAL BREATH SOUND IS VESICULAR IN
CHARACTER.
The pt lies supine with the lt arm slightly abducted.
During normal breathing, this space is percussed across BRONCHIAL BREATH SOUNDS
one or more level from its medial to lateral margin i.e
from xiphisternum to lt MAL across the 6th & 7th ICS Both inspiratory & expiratory sounds are blowig in
(BARKUN’S METHOD). character, expiratory sound is as long & as loud as the
inspiratory sound & usually of higher pitch, pause
between expiration & inspiration. Conditions associated
TRAUBE’S SPACE IS OBLITERATED IN with bronchial breath sound will produce quantitative
increase in vocal resonance i.e bronchophony &
1.Lt sided pleural effusion whispering pectoriloquy along with increased vocal
2.Massive splenomegaly fremitus. Classical site for hearing bronchial breath
3.Enlarged lt lobe of the liver sound are-Over the trachea:-the bronchial breath sound
4.Full stomach resembles that obtained by listening over the trachea
5.Fundal growth (Carcinoma of fundus) although the noise over the trachea is much louder.
6.Massive pericardial effusion >In bronchial breath sound, the expiratory sound is
7.Achalasia cardia (Often the fundal gas is absent) distinctly heard, long & loud.
8.Situs inversus totalis (Traube’s space is present on the
rt side) TYPES OF BRONCHIAL BREATH SOUNDS
TRAUBE’S SPACE IS SHIFTED UPWARDS IN 1.TUBULAR
1.Lt diaphragmatic paralysis High pitched bronchial breath sound heard in

2.Lt lower lobe collapse consolidation, collapse with patent bronchus & above
3.Fibrosis of the lt lung the level of pleural effusion. In this case, air does not
enter into the alveoli.
IV.AUSCULTATION 2.CAVERNOUS
PRE-REQUISITE FOR AUSCULTATION
Low pitched bronchial breath sound classically heard
over a superficial big empty cavity (> 2cm in diameter)
Pt should be in sitting position. Stand on the rt side of
in the lung connected with a patent bronchus e.g.
the pt. Ask the pt to turn his head to lt side & to take
tuberculous cavity, lung abscess etc.
deep breath in and out through CLOSED MOUTH (NOT
WITH OPEN MOUTH) regularly without producing any
3.AMPHORIC
noise. Demonstrate what you would like the pt to do &
then check it visually that he is doing it while you listen Low pitched bronchial breath sound with tones &
to the chest. Then simultaneously auscultate the overtones with a metallic tone which mimics the
corresponding area of rt & lt side with diaphragm of the whistling sound produced by blowing air across the
stethoscope firmly applied to the chest wall. mouth of a small glass bottle, heard over very large
>Do not auscultate over the trachea, clavicle, sternum & cavities e.g. bronchopleural fistula.
scapula. >In the exam, tell only bronchial or vesicular. Do not
>Auscultatory findings are described in relation to tell-tubular, cavernous or amphoric. But you must know
different areas of the chest wall. For example, coarse in detail about what are the different bronchial breath
crepitation is found in the infraclavicular area.

36
sounds & in which diseased conditions these are found relation to different areas of the chest wall. Whispering
so that you can answer if these are asked in the exam. pectoriloquy indicates markedly increased vocal
resonance.
TYPICAL DESCRIPTION OF BREATH SOUND
>BRONCHOPHONY & WHISPERING PECTORILOQUY ARE
1.Typical description in a normal case-Bilateral CLASSICALLY HEARD OVER CONSOLIDATION.
vesicular breath sound of normal intensity is heard >IF YOU ARE TELLING THAT VOCAL RESONANCE IS
in all areas. Or simply tell- Bilateral vesicular breath INCREASED, THEN YOU MUST TELL THAT THERE IS
sounds are heard in all areas. PRESENCE OF BRONCHIAL BREATH SOUND &
2.Breath sound is vesicular & decreased is intensity in WHISPERING PECTORILOQUY.
infrascapular area. >IF YOU ARE TELLING VOCAL FREMITUS IS INCREASED
ON PALPATION, THEN YOU MUST TELL THAT VOCAL
2.VOCAL RESONANCE RESONANCE IS INCREASED ON AUSCULTATION.
Vocal resonance is auscultatory homologue of vocal B.QUALITATIVE CHANGE

fremitus. Pt is asked to repeat NINETY NINE OR ONE-
ONE-ONE several times in a constant tone & voice (the a.AEGOPHONY
depth & intensity of voice remaining same). Both sides
of the chest are auscultated area by area, comparing It is a high pitched nasal intonation or bleating character
with the corresponding sites on the opposite side with imparted to the increased vocal resonance (meaning
diaphragm of the stethoscope. Always say vocal goat voice). It is classically found over consolidation &
resonance as normal, increased or decreased after sometimes above the level of pleural effusion.
comparing with the opposite side. Auscultate from Aegophony is audible at the upper level of pleural
above downwards in the front, sides & back of the effusion due to partially collapsed underlying lung.
chest. It is better to start from the apparently healthy Aegophony is produced by selective transmission of high
side. Do not auscultate over clavicle, sternum & scapula. frequency components of breath sounds.
Vocal resonance is described with respect to different
areas of the chest wall. >ACTUALLY, THE METHOD TO DEMONSTRATE
BRONCHOPHONY, WHISPERING PECTORILOQUY &
AEGOPHONY IS SAME AS MENTIONED ABOVE. THE
INTERPRETATION OF VOCAL RESONANCE BRONCHOPHONY & WHISPERING PECTORILOQUY
INDICATES QUANTITATIVE INCREASE IN VOCAL
A.QUANTITATIVE CHANGE RESONANCE WHILE AEGOPHONY INDICATES
QUALITATIVE INCREASE IN VOCAL RESONANCE.
a.Normal
SUMMARY OF INTERPRETATION OF VOCAL
The sound seems to be produced at the CHEST PIECE of RESONANCE
stethoscope, heard as indistinct rumble & individual
syllables are indistinguishable A.QUANTITATIVE CHANGE
b.Diminished/ Absent a.Normal

b.Decreased/ Entirely abolished
c.Increased c.Increased
1.BRONCHOPHONY-Present/ Absent
Sounds are louder & often more distinct & seems to be 2.WHISPERING PECTORILOQUY-Present/ Absent
nearer to ear than chest piece. Quantitative increase in
the vocal resonance is of two types-1.Bronchophony & B.QUALITATIVE CHANGE
2. Whisperingpectoriloquy
a.AEGOPHONY
BRONCHOPHONY
3.ADVENTITIOUS SOUND
Sound seems to appear from the EARPIECE of
stethoscope giving rise to loud clear sounds but • Rhonchi-Present/ Absent
indistinguishable words OR in otherwords, bronchopho- • Crepitation (=Rales=Crackles)
ny refers to an increased vocal resonance which is so • Absent
loud that it appears that the sound is being produced in • Present-Fine/ Coarse
the ear pieces of the stethoscope. Describe • Wheezes-Present/ Absent
bronchophony in relation to different areas of the chest • Stridor-Present/ Absent
wall. • Pleural friction rub-Present/ Absent
WHISPERING PECTORILOQUY >ADVENTITIOUS SOUNDS ARE DESCRIBED IN RELATION

TO DIFFERENT AREAS OF THE CHEST WALL i.e
Pt is asked to whisper & auscultation is carried out. The AREAWISE. FOR EXAMPLE, THERE IS FINE CREPITATION
sound seems to be spoken right INTO THE AUSC- HEARD OVER INFRASCAPULAR AREA.
ULTATOR’S EAR & is heard clearly or distinctly i.e >Fine crepitations are found in bronchopneumonia &
syllable-by-syllable. Describe whispering pectoriloquy in CHF.
37
pleuritic chest pain. Best heard at the base of the lungs
WHEEZES & at the lower parts of the axillary region (generally
heard over the antero-inferior part of the lateral chest
High pitched musical sound heard from a distance, wall or over the lower part of the back as the movement
better heard in expiratory phase, usually associated with of the lung is maximum in these regions). Better heard
rhonchi, indicates small airways obstruction. on pressing the diaphragm of the stethoscope over the
chest wall. The rub disappears when breath is held.
STRIDOR Sometimes the rub can be felt with the palpating hand
when it is called as the FRICTION FREMITUS. The sound
Low pitched crowing sound heard from a distance, does not alter after coughing & with change of posture.
better heard during inspiration, indicates larger airways Press the diaphragm of the stethoscope to note the local
obstruction like larynx, trachea & major bronchus, very tenderness & increase in the intensity of pleural rub
common in children. In otherwords, stridor is the noisy .
breathing produced by turbulent airflow through 4.SUCCUSSION SPLASH(HIPPOCRATIC SUCCUSSION)
narrowed airways.
-Present/ Absent
TYPES OF STRIDOR
This is done if HYDROPNEUMOTHORAX is suspected. Ask
1.INSPIRATORY STRIDOR the pt to sit up & place his hands above his head. Now
by percussion, the upper border of dullness is detected
Produced due to obstruction in supraglottic region, e.g in the lateral chest wall along the MAL in sitting position
Laryngomalacia, retropharyngeal abscess of the pt. Now the diaphragm of the stethoscope is
placed on the upper border of dullness & the pt is
2.EXPIRATORY STRIDOR shaken from side to side vigorously. A splashing sound
(like splashing sound of an intact coconut) is audible
Produced due to obstruction in thoracic trachea, primary with every jerk. Sometimes the sound can be heard
bronchi & secondary bronchi, e.g Tracheal stenosis, without stethoscope (unaided ear i.e ear placed over the
bronchial foreign body chest wall & the pt is shaken from side to side). (The
stethoscope may be placed on the anterior chest wall).
3.BIPHASIC STRIDOR Succussion splash in the chest is ALWAYS
PATHOLOGICAL.
Produced due to obstruction in glottis,subglottis & >In the rt side, succussion splash is always pathological,
cervical trachea, e.g Laryngeal papilloma, vocal cord but in lt side, it may be due to fluid in the stomach.
palsy, subglottic stenosis
5.SCRATCH TEST
>Types of crepitation in relation to phases of respiration (=SCRATCH SIGN=FRICTION TEST)
1.Inspiratory-Early/ Mid/ Late
2.Expiratory -Positive/ Negative
TYPES OF RHONCHI It is done if PNEUMOTHORAX is suspected. Diaphragm

of the stethoscope is placed on the mid-point of the
A.MONOPHONIC sternum & is held in position with the lt hand. Then the
anterior chest wall is scratched with the fingers of the rt
May be inspiratory or expiratory or both & may change hand at a point equidistant to the lt & rt of the
in intensity with change of posture. It is produced due stethoscope alternatively. Start scratching from the
to narrowing of a single bronchus by tumor or foreign lateral aspect and move gradually towards the mid-
body (i.e localized obstruction). sternal line. The sound heard is louder when the
affected side of the chest wall (having pneumothorax) is
B.POLYPHONIC scratched.
Particularly heard in expiration & are characteristically 6.COIN TEST (=BELL TYMPANY)
found in diffuse airflow obstruction eg. bronchial asthma
or chronic bronchitis. They denote dynamic compression -Positive/ Negative
of bronchi. This is the most common type of rhonchi
1.PREFERRED METHOD
where the musical sound contains several notes of
different pitch & results from oscillation of many large Ask the pt to place an 1 ruppee coin over the upper part
bronchi at a time. Do not utter the word monophonic & of front of the affected side chest & percuss the coin
polyphonic in the examination unless you are asked. with a second 1 ruppee coin. The examiner stands
behind the pt & listens at the back just diametrically
PLEURAL FRICTION RUB opposite to the point of percussion with the diaphragm
of the stethoscope. A high-pitched tympanitic or metallic
Creaking or rubbing, superficial (the sound seems to be (bell-like) sound will be heard in case of tension
very close to the ear), scratching or grating in character pneumothorax. This metallic sound is called as coin
heard towards the end of inspiration & just after the
beginning of the expiration usually in association with
38
sound, bell sound, bell tympany, bruit-de-airain or diatal 3.UMBILICUS
anvil sound.
• Location-Central (Midway between xiphisternum &
2.ALTERNATIVE METHOD symphisis pubis/ Displaced up OR Displaced down/
Displaced to rt OR Displaced to lt
Ask the pt to fix the diaphragm of yours stethoscope • Inverted/ Everted
over the anterior chest wall while you yourself put a coin • Shape-Circular/ Transversely slit/ Vertically slit
in the pt’s back & strike with second coin by standing
behind the pt.
>Transversely slit umbilicus is known as laughing
>Coin percussion is positive in PNEUMOTHORAX umbilicus.
(TENSION PNEUMOTHORAX) & OVER LARGE CAVITIES. >Normally, umbilicus lies more or less in the midway
Coin percussion is done only when pneumothorax between xiphisternum and symphysis pubis. Normally, it
is suspected. is inverted and slightly retracted, and its slit is circular.
Umbilicus is everted in any condition giving rise to
increased intra-abdominal tension like ascites, ovarian
GASTROINTESTINAL cyst, pregnancy, polyhydramnios, severe gaseous
distension etc. Its slit is transverse in ascites and
SYSTEM EXAMINATION vertical in ovarian cyst.
>TANYOL’S SIGN-Downward displacement of umbilicus
I.INSPECTION in ascites.
>Any swelling on one side of the abdomen will push the
umbilicus to the opposite side.
A.UPPER GIT
4.FLANKS
1.LIPS
-Full/ Flat (Empty)
2.ANGLE OF MOUTH
Flanks are full in ascites & flat in ovarian tumor.
-Healthy/ Angular stomatitis
5.CONDITION OF SKIN
3.TEETH
-Healthy/Scar mark/ Scratch mark/ Yellow discoloura-
-Chewing surfaces are normal/ Caries
tion/ Ulcer/ Ecchymosis / Scaly/ Puncture mark/ Shiny
4.GUMS
6.ANY LOCALISED SWELLING
-Healthy/ Bleeding/ Hypertrophy
7.MOVEMENT OF THE ABDOMEN
5.TONGUE
-Respiratory movement/ Peristalsis/ Pulsation
a.Size (=Bulk)-Normal/ Atrophy/ Hypertrophy (epigastrium)
b.Surface-Normal/ Smooth/ Bald >Adequate in all quadrants in a normal case.
c.Color-Pink/ Pale/ Beefy red
d.Ulcer-Present/ Absent 8.HERNIAL ORIFICES
See the inferior surface, superior surface, tip & margins -Inguinal/ Femoral/ Umbilical/ Epigastric/ Incisional
of the tongue to find out the above abnormality. All hernial orifices are intact in a normal case.
9.SCROTUM
6.THE ORAL CAVITY (mucous nenbrane of mouth)
-Healthy/ Edematous/ Hydrocele (In nephrotic
-Moderate in hygiene/ Mouth ulcers syndrome)/ Other
B.ABDOMEN II.PALPATION
PRE-REQUISITE FOR ANY ABDOMINAL PALPATION
1.SHAPE OF THE ABDOMEN
Always stand on the rt side of the pt. Pt lies in supine
-Scaphoid/ Distended or Swollen or Protuberant position with head supported with a pillow & hands lying
by the side of his trunk. Expose the abdomen from
2.VENOUS PROMINENCE xiphisternum to just above the inguinal ligament. Then
semiflex the lower limb at hip joint & knee joint to relax
• Around umbilicus-Present/ Absent the abdominal wall muscles. Turn the pt’s head to the lt
• At flanks (About mid-axillary line)-Present/ Absent & ask him to breathe deeply but regularly with open
mouth. SEMIFLEXION OF THE HIP JOINT & KNEE

39
JOINT IS A MUST FOR ALL ABDOMINAL downwards as venous valve prevents retrograde flow &
PALPATION. if the vein remains full, the direction of blood flow is
from below upwards. If you find that the engorged vein
A.SUPERFICIAL PALPATION refills from both direction (i.e from above as well as
below) then it is the rapidity of refilling which
1.TENDERNESS determines the direction of flow i.e the direction of blood
flow is towards the direction of rapid refilling.
-Absent/ Present in_______area or at Mc Burney’s
point/ Galldder point/ Epigastrium/ Renal angle >It is preferable to choose a vein below the umbilicus
for demonstration of venous flow in engorged abdominal
2.CONSISTENCY(FEEL) wall veins. Engorged & tortuous veins always indicate
some underlying pathology.
-Normal elastic/ Tense OR Rigid >NORMALLY, THE DIRECTION OF BLOOD FLOW IN THE
>Determine by superficial palpation. VEINS ABOVE THE UMBILICUS IS FROM BELOW
UPWARDS & IN THE VEINS BELOW UMBILICUS IS FROM
3.DIRECTION OF BLOOD FLOW IN PROMINENT ABOVE DOWNWARDS (i.e AWAY FROM UMBILICUS).
VEINS
VISIBLE VEINS VERSUS ENGORGED VEINS
a.AROUND UMBILICUS
Sometimes, veins are visible normally in thin built
-Towards/Away from umbilicus persons (often in fair-skinned individuals) & are usually
present at the skin level i.e flushed with the skin. But
b.ABOUT MID-AXILLARY LINE the engorged vein is bit raised from the skin surface.
Palpate the vein lightly by rt index finger & draw your
-From above downwards/ From down upwards inference. Visibility of a vein does not mean that it is
pathological engorgement & moreover, tortuosity
>Portal hypertension-There is periumbilical engorged indicates its pathological nature.
veins with direction of blood flow away from the
4.FLUID THRILL
umbilicus (Caput medusae).
-Present/ Absent
>IVC obstruction-Direction of blood flow is-
1.Above the umbilicus-Upwards & away from umbilicus Pt lies in supine position. Do not semiflex pt’s lower limb
2.Below the umbilicus-Towards the umbilicus. In inferior at hip joint & knee joint (as you are doing for other
venacaval obstruction, engorged veins are found at the abdominal palpations) to relax the abdominal wall
flanks. In general, remember that in IVC obstruction, muscles because, for fluid thrill, there is no need to
the flow of blood in engorged veins is from below relax the abdominal wall, rather you have to make the
upwards. abdominal wall tense by putting pt’s hand as described
subsequently. Either the pt or a third person (but never
>SVC obstruction-The engorged veins are found above ask the examiner to put his hand) will put his ulnar
the umbilicus with flow of blood from above downwards. border of rt hand vertically (along the longitudinal axis)
over the abdomen in the midline (to prevent
METHOD TO DETERMINE THE PRESENCE OF DILATED & transmission of vibration through the abdominal
TORTUOUS VEINS ON ABDOMINAL WALL/CHEST WALL parieties). Then place your lt palm over the lt flank &
sharply tap or flick the rt flank with your rt index finger.
Ask the pt to sit with the legs hanging from the bed A fluid thrill is felt by your lt palm as a definite impulse.
(never examine in lying down position) & ask him to You can tap the lt flank & feel the impulse over rt flank,
cough or to perform the Valsalva maneuver. Coughing but for this you have to stand on the lt side of the pt. 1
makes the veins prominent transiently while the to 2 liter of fluid is required for this. USG can detect
Valsalva retains the prominence of veins so long as the even 100 ml of peritoneal fluid.
maneuver is continued. Proper light is necessary (pt
fecing the window) for demonstration. 5.PULSATION
METHOD TO DETERMINE THE DIRECTION OF BLOOD -Transmitted/Expansile

FLOW IN DILATED & TORTUOUS VEINS ON ABDOMINAL
WALL/CHEST WALL
6.PARIETAL EDEMA
Make the veins prominent by aforementioned method.
-Present/Absent
Then place two index fingers of both hands side by side
on the tributary free long segment (one inch or more)
EXAMINATION FOR PARIETAL EDEMA
of the prominent vein. Then gently press & move the
lower index finger away, thus emptying part of the vein.
Edema of the parieties (eg.abdominal wall) is assessed
Then remove the lower index finger & see whether the
by pinching the skin at the flanks with rt thumb & rt
vein remains empty or becomes full again. If the vein
index finger for few seconds (AT LEAST FOR 5
remains empty, the direction of blood flow is from above
SECONDS). [Other mrethods-Press the diaphragm of the
40
stethoscope or the tip of fingers of the abdominal Usually a soft liver has round margin, & firm or hard
parieties or thigh for a few seconds (AT LEAST FOR 5 liver has sharp margin. Margin may be irregular in
SECONDS) & look for pitting edema there.] cirrhosis of liver. Soft liver can not have sharp margin
>Parietal edema is usually found in anasarca caused by i.e it must have round margin. Hard liver can not have
nephritic syndrome. round margin i.e it must have sharp margin.
7.MAXIMUM GIRTH OF THE ABDOMEN IN cm d.Consistency-Soft/ Firm/ Hard
a.At umbilicus e.Surface-Smooth/ Granular/ Nodular/ Irregular

b.Below umbilicus
c.Above umbilicus Normal liver is soft in consistency & has round margin.
Measure with a measuring tape & express in cm.
f.Moves with respiration
>Do not tell this in the exam. Tell this only if you are
asked. g.Left lobe-Enlarged/ Not enlarged
>This is done to know whether the ascites or intestinal
Rt lobe of the liver is palpated by keeping the hand
obstruction or any other cause of abdominal swelling
lateral to the Rt. rectus abdominis muscle while the Lt.
which are treated are improving (i.e responding to
lobe is palpated in the midline.
treatment) or not.
h.Upper border of liver dullness-Starts from
8.SPINO-UMBILICAL DISTANCE IN cm
rt___ICS at MCL
Measure the distance between umbilicus & anterior
NOTE- It is mandatory to tell that the liver is enlarged
superior iliac spine with a measuring tape & express in
instead of liver is palpable, because it is obvious that a
cm.
enlarged liver is always palpable, but a palpable liver is
not always enlarged. That means there are certain
B.DEEP PALPATION conditions like Emphysema, subdiaphragmatic abscess
etc. in which an unlarged liver is displaced downwards
PRE-REQUISITE FOR ANY ABDOMINAL PALPATION so that it becomes palpable. So a palpable liver may or
may not be enlarged, but an enlarged liver is always
Always stand on the rt side of the pt (you will be failed if palpable. A palpable liver may or ay not be pathological,
you examine the pt by standing on the lt side of the pt). but an enlarged liver is always pathological. But it is
Ask the pt to lie down in supine position with head mandatory to tell that the spleen is palpable instead of
supported with a pillow & hands lying by the side of his spleen is enlarged, because spleen is palpable only
trunk. Expose the abdomen from xiphisternum to just when it is enlarged 2 times than its normal size. That
above the inguinal ligament. Then semiflex the knee means a palpable spleen is always enlarged &
joint to relax the abdominal wall muscles. Turn the pt’s pathological.
head to the lt & ask him to breathe slowly, smoothly &
deeply but regularly with open mouth. SEMIFLEXION PERCUSSION OF UPPER BORDER OF LIVER
OF THE HIP JOINT & KNEE JOINT IS A MUST FOR
ALL ABDOMINAL PALPATION. No anterior abdominal Start percussion from above downwards in the rt chest
wall muscles are inserted to the lower limb, but still we along the rt MCL. It is a heavy percussion as upper
flex the lower limb to relax the anterior abdominal wall, border of liver lies under cover of the rtlung. Place the
because the “Tensor Fascia Lata” of the thigh is pleximeter finger in the rt 2nd ICS parallel to the
attached superiorly to the inguinal ligament which is arbitary upper border of liver & the line of percussion
nothing but the lower inwardly curved portion of the will be perpendicular to that border. Normally when
external oblique aponeurosis (which is an anterior percussed, UPPER BORDER OF LIVER DULLNESS STARTS
abdominal wall muscle). So if you do not flex the lower FROM RIGHT 5 TH ICS ALONG MCL, RIGHT 7 TH ICS
limb during abdominal palpation, the Tensor Fascia Lata ALONG MAL & RIGHT 9 TH ICS ALONG SCAPULAR LINE.
will pull the inguinal ligament down thereby making the Upper border of liver dullness is displaced upwards in
anterior abdominal wall tense. upward enlargement of liver.
1.LIVER i.Any pulsation-Felt/ Not felt
a.Enlarged___cm below the costal margin at rt METHOD TO PALPATE PULSATILE LIVER

MCL (Measurement taken during normal expiration).
Stand on the rt side of the patient. Ask the pt to lie
b.Tenderness-Tender/Nontender down in supine position & semiflex his hip & knee joint
as in any abdominal palpation. Place your rt palm over
While examining for liver tenderness, look to pt’s face the rt hypochondrium (never put your palm over
for grimacing due to pain. epigastrium) & the lt palm over the back, just opposite
the rt palm (as in bimanual palpation of kidney). Ask the
c.Margin-Sharp (palm leaf)/ Rounded/ Irregular pt to hold his breath after taking deep inspiration. Then

41
look from the side & observe the separation of the method. Similar method is used for palpating spleen in
hands along with expansile pulsation of the liver. ascites.
>Tell liver is not enlarged. Don’t tell-Liver is not
palpable. In pediatrics, tell liver is palpable if it is >Never forget to palpate the lt lobe of the liver, to
enlarged. percuss the upper border of the liver & to palpate
bimanually for liver dullness.
METHODS TO PALPATE LIVER
2.SPLEEN
A.CONVENTIONAL METHOD
a.Palpable___cm below the costal margin rt MCL
Pre-requisites are mentioned earlier. Place the flat of b.Tenderness-Tender/ Nontender
the rt palm firmly over the rt iliac fossa parallel to the rt c.Consistency-Soft/ Firm/ Hard
subcostal margin (or the arbitary lower border of liver) d.Surface-Smooth/ Irregular
& lateral to the rt rectus abdominis muscle. At the e.Splenic notch-Felt/ Not felt
height of inspiration press the fingers firmly inwards & f.Moves with respiration
upwards (don’t press your hand very hard). The radial g.Inability to insinuate the finger between the
border of the rt index finger will slip over the lower mass & costal margin
border of the liver, if it is enlarged. At each phase of h.Palpable splenic rub-Present/ Absent (for this, pt must
expiration, glide your rt palm over the abdomen & place breathe in & out deeply)
the rt palm at a 2 cm higher level from the previous
level (never lift your rt palm from the abdomen at any
>TELL SPLEEN IS NOT PALPABLE. DON’T TELL-SPLEEN IS
cost). In this way go on palpating upwards in search of
NOT ENLARGED.
the lower border of the liver. Now palpate the
epigastrium for the lt lobe of the liver. Look to pt’s face
for any pain (Tender Hepatomegaly). >MASSIVE SPLENOMEGALY-Spleen is enlarged > 8
cm below the left costal margin or its drained weight is
B.PREFERRED METHOD ≥ 1000gm.
Pre-requisites are mentioned earlier. Place both hands ! SPLENOMEGALY

side by side flat on the anterior abdominal wall in the rt 1.Mild-Above the umbilicus or upto 5 cm
subcostal region lateral to the rt rectus abdominis 2.Moderate-At the umbilicus or 5 to 8 cm
muscle with the fingers pointing towards the ribs. If any 3.Severe-Below the umbilicus or > 8 cm
resistance is felt, move the hands further downwards
until the resistance disappears. The pt is then asked to ! SPLENOMEGALY-
breathe deeply & at the height of the inspiration press 1.Tip enlargement of 1 to 2 cm
the finger upwards & inwards. The process is repeated 2.Moderate enlargement of 3 to 7 cm
from lateral to medial side to trace the lower border of 3.Marked enlargement of 7+ cm
the liver as it passes upwards to cross from rt
hypochondrium to epigastrium. When the hand is METHODS TO PALPATE SPLEEN
moved downwards, the loss of resistance demarcates
the lower border of liver.
A.BIMANUAL PALPATION
C.ALTERNATIVE METHOD
Pre-requisites are same as mentioned in liver palpation.
Pre-requisites are mentioned earlier. The rt hand is Stand on the rt side of the pt. Ask the pt to breathe in &
placed flat in the rt iliac fossa with the fingers directing out slowly, smoothly & deeply but regularly with open
upwards, lateral to the rt rectus abdominis muscle. At mouth. Palpate the spleen with the fingertips of the rt
the height of inspiration, the hand is pressed firmly hand starting from the rt iliac fossa. Glide your rt hand
inwards & upwards.With the inspiration the tips of the upwards & laterally towards the lt hypochondrium at
fingers will slip over the edge of the liver, if palpable. 2cm intervals with each respiration till fingertips of the
The lt hand may be placed in the lower part of the rt rt hand reach the lt costal margin. As the lt costal
chest wall posteriorly. Now palpate the surface, feel the margin is approached, place your lt hand firmly over the
consistency etc.as a routine. lt costal margin posterolaterally & press it forward &
medially. Start well out to the lt costal margin &
D.DIPPING METHOD gradually move more medially if spleen is not found. At
the height of inspiration, release pressure on the
This method is used in ascites. Pre-requisites are same examing hand so that the fingertips slip over the lower
as mentioned above. Give two sharp taps in quick pole of the spleen, confirming its presence & surface
succession at the rt subcostal region by the tip of the characteristics. It is better to palpate the spleen with
four fingers (except thumb) of the rt hand by flexing the the fingertips but few clinicians prefer to use the radial
fingers at the metacarpophalangeal joint. The sudden border of the rt index finger to palpate the spleen where
thrust causes sudden & rapid displacement of fluid & the radial border of rt index finger is placed parallel to
gives a tapping sensation over the surface of the the lt costal margin. Contracting rectus abdominis
enlarged liver which is comparable to patellar tap. It is may be confused with palpable spleen.
better to start palpation from rt iliac fossa for dipping

42
B.If a spleen is not palpable (or is a just palpable
4.ANY OTHER MASS
spleen) by the method mentioned above, turn the pt to
rt lateral position & ask him to relax upon your lt hand 1.Site
which is now supporting the lower ribs with the lt hip & 2.Size
knee flexed & palpate the spleen by the same palpatory 3.Surface
method mentioned above (palm lying flat) while the pt 4.Skin over it
is breathing in & out deeply. The examiner’s lt hand 5.Edge
should remain over the lowermost rib cage 6.Extension
posterolaterally on the lt side as mentioned above. >Tell only if present. Otherwise don’t tell.
C.In case of just palpable spleen, finally stand on the lt 5.HERNIAL ORIFICES
side of the pt facing the foot end of the bed. Palpate the
spleen by the HOOKED FINGERS (curling the fingers of • Inguinal/ Femoral/ Umbilical/ Epigastric/ Incisional
the examining hand) of the lt hand below the lt costal • Effect of coughing
margin as the pt breathes in deeply. Hooking method
may be done from the lt side in sitting position of the pt. >All hernial orifices are intact in a normal case.
>If the spleen is not palpable by method A, go for >In the exam, you must examine the ingunal hernial
method B & then for method C. Method A & B may be site & tell that all hernial sites are intact. In all
called bimanual palapation. While palpating spleen, do abdominal cases, it is mandatory to examine the hernial
not be hasty & rash, rather show endurance as a just sites, at least the inguinal hernial sites.
palpable spleen will definitely touch your finger at the 6.TESTIS (both sides)
height of inspiration.
III.PERCUSSION
D.DIPPING METHOD
1.GENERAL NOTE OF THE ABDOMEN
This method is used in ASCITES & is performed similarly
as mentioned in liver palpation in ascites. -Dull/ Tympanic
3.KIDNEY 2.LIVER DULLNESS/LIVER SPAN
-Ballotable/ Not ballotable It is the vertical distance between the uppermost & lo-
>Prerequisities are same as mentioned in liver wermost points of hepatic dullness. It is detected by
palpation. percussing the upper & lower borders of liver at the rt
MCL. Percussion of the upper border of liver-Start
RIGHT KIDNEY percussion from above downwards in the rt chest along
rt MCL (You may start percussion fron the 5th ICS
Place the rt hand horizontally in the rt lumbar region onwards as the upper border border of liver lies below
anteriorly & the lt hand is placed posteriorly in the rt the 5th rib?). It is a heavy percussion (as the upper
loin (bimanual palpation). Ask the pt to take deep border of liver lies under cover of the right lung). Place
breath in while you push forwards with the lt hand & the pleximeter finger in the rt 2nd ICS parallel to the
press the rt hand backwards, upwards, & inwards. A arbitary upper border of liver & the line of percussion
firm mass may be felt between the two hands (if kidney will be perpendicular to that border. Percussion of the
is enlarged). Next a sharp tap is given by the lt hand lower border of liver-Start percussion from below
placed in the loin. The anteriorly placed rt hand now upwards i.e from rt iliac fossa to rt hypochondrium
feels the kidney & the kidney then falls back (by along the rt MCL. It is a light percussion. Place the
gravity) on the posterior abdominal wall which is felt by pleximeter finger parallel to the rt subcostal margin &
the lt hand. This is ballotment. the line of percussion will be perpendicular to that
margin? Mark the dullness with a pen above and below
LEFT KIDNEY and then measure the distance between the points with
a measuring tape or measure the distance with fingers
Palpate from the rt side, not from the lt side. The rt and convert into cm by multiplying with 1.5?
hand is placed anteriorly in the lt lumbar region while >The normal liver span is 12-15cm in adult. Normally
the lt hand is placed posterior in the lt loin. Ask the pt to the upper border of liver dullness is present in rt 5th
take deep breath in & then press the lt hand forwards & ICS along MCL, in rt 7th ICS along MAL & in rt 9th ICS
the rt hand backwards, upwards & inwards. Lt kidney’s along scapular line. Serial measurement is helpful to
lower pole, when palpable is felt as a round firm detect shrinkage or enlargement.
swelling between both rt & lt hands (i.e bimanually >Tell about the liver span only when you are asked. Do
palpable) & it can be pushed from one hand to the other not tell as a routine.
(i.e balloting). >In emphysema and pneumothorax, the liver is
>Assess the size, surface & consistency of a palpable displaced downwards without being enlarged.
kidney.
>A kidney lump is bimanually palpable & bimanually 3.SPLENIC DULLNESS
ballotable.
43
flank occupies the highest point of the pt’s body. Now
METHOD TO PERCUSS FOR SPLENIC DULLNESS wait for 30 TO 60 SECONDS for the intestine to float
up and then percuss the flank where pleximeter finger is
It is accomplished by any of the following three methods placed which will be tympanitic now.Continue percussing
described by Nixon, Castell or Barkun. from the flank back towards the midline which will be
dull now. So the dullness in the flank changes to
1.NIXON’S METHOD tympanitic note & tympanitic note in the midline
changes to dull note. Do in both sides. Never allow the
The pt is placed on the rt side so that the spleen lies other fingers except the pleximeter finger to touch
above the colon and stomach. Percussion is begun at the abdominal wall while percussing. It is the
the lower level of the pulmonary resonance and shifting of dullness and not the shifting of resonance.
proceeds diagonally along a perpendicular line toward
the lower midanterior costal margin. The upper border >In case of pregnancy and large ovarian cyst, the
of dullness is normally 6 to 8 cm above the costal central part abdomen is dull (in contrast to ascites
margin. Dullness > 8 cm in an adult is presumed to where the central part is tympanic) while the flanks are
indicate splenic enlargement. tympanic (in contrast to ascites where the flanks are
dull).
2.CASTELL’S METHOD >Shifting dullness is the diagnostic sign of free fluid in
the abdomen i.e ascites.
With the pt supine, percussion in the lowest ICS in the >In ascites, fluid thrill may be absent.
anterior axillary line (8th or 9th) produces a resonant
>Shifting dullness is absent when there is accumulation
note if the spleen is normal in size. This is true during
expiration or full inspiration. A dull percussion note on of very large quantity of fluid.
full inspiration suggests splenomegaly. >Ascites is clinically recognized only when the amount of
fluid present in the peritoneal cavity exceeds 150 ml.
3.BARKUN’S METHOD (PERCUSSION OF TRAUBE’S >In loculated ascites (found in TB), ther is no shifting
SEMILUNAR SPACE) dullness.
As mentioned in the examination of respiratory system. UNILATERAL SHIFTING DULLNESS=BALANCE’S SIGN
4.SHIFTING DULLNESS This is found in the splenic rupture wherein the blood
present in the lt flank (i.e near the spleen) clots &
-Present/ Absent doesn’t shift to rt side in rt lateral position, but the
blood present in the rt side (hemoperitoneum) shifts to
PRINCIPLE OF SHIFTING DULLNESS lt side in lt lateral position.
When there is fluid in the abdominal cavity, the fluid 5.PUDDLE SIGN
causes the intestines (bowel loops) to float up i.e they
come to lie beneath the anterior abdominal wall when -Positive/ Negative
the pt is in supine position. These bowel loops contain
gas which gives a resonant note when the the anterior >First percuss the abdomen in supine position where
abdominal wall is percussed. So there is no need to you get a tympanitic note in the midline. Now place the
semiflex pt’s lower limb while percussing for shifting pt on hands & knees i.e KNEE-ELBOW POSITION for 5
dullness. minutes & percuss over the lowest part of the
suspended (near umbilicus) abdomen which now reveals
PROCEDURE OF SHIFTING DULLNESS a dull note due to shifting of fluid.
>This sign is actually elicited by AUSCULTO-PERCUSSION
Pre-requisites are same as mentioned above except that
i.e placing the bell of the stethoscope over the lowest
there is no need to semiflex pt’s lower limb at hip joint
part of the suspended abdomen in knee-elbow position
& knee joint (as you are doing for other abdominal
& then repeatedly flicking near the flank with the finger
palpations) to relax the abdominal wall muscles. Now
while the stethoscope is gradually moved towards the
palpate the abdomen for any visceromegaly (by dipping
opposite flank. In a positive case, there is marked
method). If any viscous is enlarged, try to avoid
change in the intensity & character of the percussion
percussion over them. Then starting from the
note as the stethoscope leaves the lowest (PUDDLING)
epigastrium, percuss in the midline from above down-
zone. In order to confirm the validity of the test, the pt
wards & note the maximum point of tympanicity which
is asked to sit up while the stethoscope is held on most
is usually somewhere around the umbilicus (In the
dependent area & flicking of the abdominal wall is
examination, you may avoid this step). Now percuss
repeated. If now the percussion note becomes loud &
laterally at 1 cm intervals to that side where there is no
clear, the initial impression of puddling of fluid is
enlargement of organs from the maximum point of
considered to be correct.
tympanicity noted in the midline, keeping the pleximeter
finger parallel to long axis of abdomen. When you get a
dull note, go on percussing upto the end of the flank. IV.AUSCULTATION
Then turn the pt to other side keeping the pleximeter
finger at the flank so that the pleximeter finger on the

44
1.BOWEL SOUND SEMICONSCIOUS, STUPOROUS & COMATOSE Pt, NEVER
EXAMINE THE HIGHER FUNCTIONS.
: ____bowel sounds/ minute
1.LEVEL OF CONSCIOUSNESS
>Place the stethoscope over Epigastrium/ Right iliac
a.Pt is conscious & co-operative
fossa & keep it there for 1 minute. Normal bowel sounds
are intermittent, low or medium pitched gurgles mixed
CONSCIOUS
with occasional high-pitched tinkle.
>In mechanical intestinal obstruction, frequent, loud, Relates to a person who is alert, attentive & co-
lowpitched gurgles (borborgymi) are heard often operative. Actually it is a state of awareness of one’s
interspersed with high-pitched tinkles occurring in a self & environment.
rhythmic pattern with peristalsis. As a whole, the
peristaltic sounds are exaggerated. In paralytic ileus, b.Stupor/ Confusion/ Drowsy/ Semicoma/ Coma/
abdomen is silent (bowel sounds are not heard). Akinetic mutism (=Persistent vegetative state)/ Locked-
in syndrome (=De-efferented state)
2.VENOUS HUM
CONFUSION
-Present/ Absent
Do not tell in examination if not asked. 1.Fluctuation in awareness, associated with agitation,
fright, confusion i.e disorientation. It denotes
3.SPLENIC RUB incapacity of the pt to think with customary speed &
clarity. The pt is conscious, but often talks
-Present/ Absent irrelevantly. It is associated with misperception of
Do not tell in examination if not asked. environment, hallucination, delusion etc.
2.The confused pt is usually subdued, not inclined to
4.RENAL ARTERY BRUIT speak & is physically inactive.
3.A state of confusion that is accompanied by agitation,
-Present/ Absent hallucinations, tremor & illusions (misperceptions of
Do not tell in examination if not asked. environmental sight, sound or touch) is termed
delirium, as typified by delirium tremens from alcohol
or drug withdrawal.
V.PER-RECTAL EXAMINATION 4.In some instances, the apparent confusional state
may be due to an isolated deficit in mental function
>Boggy fluctuant swelling in the rectovesical pouch or such as an impairment of language (aphasia), loss of
Pouch of Douglas is due to collection of free fluid in memory (amnesia) or lack of apprehensions of spatial
ascites. relations of self or the external environment
>Tell only if you have done this, otherwise do not tell (agnosia).
falsely.It is usually not done. 5.Confusion is also a feature of dementia in which case
the chronicity of the process distinguishes it from the
VI.SPECIAL SIGNS acute encephalopathy.
6.Confusion definition-Confusion is a mental &
behavioural state of reduced comprehension,
coherence & capacity to reason.
NERVOUS SYSTEM
DROWSY
EXAMINATION
1.Pt appears to be in normal sleep but can not easily be
CNS-It consists of brain, spinal cord & the first two awakened & once awake, he tends to fall asleep
cranial nerves, while the remaining cranial nerves & the despite verbal stimulation or clinical examination.
spinal nerves constitute the PERIPHERAL NERVOUS 2.Pt cannot be fully aroused, but may open eyes & show
SYSTEM. tongue after vigorous painful stimulation which is brief
& incomplete.
I.HIGHER FUNCTION
STUPOROUS
EXAMINATION
1.Pt is not aware of surroundings, but responds to
PRE-REQUISITE FOR HIGHER FUNCTION painful stimuli (pinching or supraorbital pressure) by
EXAMINATION groaning or simple withdrawal of the stimulated part
of the body.
HIGHER FUNCTION IS TESTED ONLY WHEN THE PATIENT 2.Give sternal rub & supraorbital pressure to distinguish
IS FULLY CONSCIOUS & IS NEVER TESTED IF THE between stuporous pt from comatose pt.
PATIENT HAS ALTERED SENSORIUM SINCE TESTING OF 3.Sternal rub is given by rubbing examiner’s knuckles of
HIGHER FUNCTION REQUIRES Pt’S CO-OPERATION &
right hand (Flexed proximal interphalangeal joint of
WITHOUT Pt’S CO-OPERATION, IT IS IMPOSSIBLE TO
TEST THE HIGHER FUNCTIONS. SO IN UNCONSCIOUS, fingers).

45
4.Supraorbital pressure is given by applying painful 5.If the eyes are closed because of swelling, record: C
stimuli by pressing upward the medial side of the orbit
above the medial canthus (i.e medial aspect of the B.VERBAL RESPONSE (V)
upper margin of the orbit) of two sides simultaneously
with both thumbs i.e lt thumb for the rt side & rt a.VERBAL RESPONSE (NONINTUBATED Pt)
thumb for the lt side. Look for facial grimacing.
RESPONSE SCORE
Oriented & talks 5
COMA Disoriented & talks (Confused) 4
Pt is not oriented to time, place
Pt shows no psychologically meaningful response to & person.
external stimuli or internal need of any kind & the pt is
Inappropriate words 3
deeply unconscious.
Incomprehensible sounds 2
(i.e the sounds can not be
LOCKED-IN SYNDROME = DE-EFFERENTED STATE
understood)
No response 1
" Pt is awake, but is completely immobile (i.e can’t
make any volitional movement) & can’t produce
b.VERBAL RESPONSE (INTUBATED Pt)
speech to indicate that he is awake. Pt is able to
communicate only by verticak eye movement, lid
elevation & blinking which remain unimpaired. RESPONSE SCORE
" Cause- It is usually due to bilateral ventral pontine Seems able to talk 5
lesion due to infarction or hemorrhage which transects Questionable ability to talk 3
all descending coticospinal tracts & coticobulbar tracts. Generally unresponsive 1
EEG is normal.
" Patient EXPLANATION
1.Is quadriplegic (bilateral damage to corticospinal
tract in ventral pons) 1.Address the pt by name: “Mr…………, tell me where you
2.Is unable to speak & incapable of facial are.”Ask his full name & address-What day it is,
movements (involvement of corticobulbar tracts) month, year? If the patient answers correctly, then
3.Has limited horizontal eye movements (bilateral record: Oriented
involvement of nuclei & fibres of 6th cranial nerve) 2.If the pt answers incorrectly, record: Confused
4.Has intact vertical eye movements & blinking 3.If oriented only in some respects, then expand on this
(supranuclear ocular motor pathways are spared) in observation coloumn.
5.Has preserved consciousness (reticular formation 4.If reply is not related to the question, then record:
is not damaged) Inappropriate
5.If the pt’s reply is incoherent, record: Incoherent
AKINETIC MUTISM 6.If the pt makes no reply, record: None
(=PERSISTENT VEGETATIVE STATE) 7.If the pt has a tracheostomy, record: T
>Now a day, the degree of coma or the level of C.BEST MOTOR RESPONSE (M)
consciousness is assessed by Glasgow coma scale.
RESPONSE SCORE
GLASGOW COMA SCALE (GCS) Obeys verbal command 6
Localizes pain 5
It has 3 components-E, V & M. Flexion withdrawal to pain 4
(Withdraws to pain)
A.EYE OPENING (E) Abnormal flexion posture 3
(decorticate rigidity)
RESPONSE SCORE Abnormal extension posture 2
Spontaneus 4 (decerebrate rigidity)
To loud voice 3 No response 1
(To speech)
To painful stimuli 2 DECEREBRATE POSTURE
No response 1
Extended elbows & wrists with arms pronated. The
EXPLANATION lesion lies at the brainstem level, disconnecting cerebral
hemispheres from brainstem.
1.If the pt opens eyes spontaneously to observe
DECORTICATE POSTURE
surroundings, record: Spontaneous
2.If the eyes are not spontaneously open, call the pt by
Flexed elbows & the wrists with arms supinated. It is
name: If the eyes open then record: To speech
3.If the eyes do not open to the name, apply sternal rub seen in bilateral hemispherical lesion above midbrain.
Decorticate rigidity is seen on the hemiplegic side in
(with the knuckles): If eyes open, then record:To pain
4.If the eyes still have not opened, record: None
46
humans after hemorrhages or thromboses in the ABBREVIATED COMA SCALE (AVPU)
internal capsule.
RESPONSE SCORE
EXPLANATION Alert A
Responds to V
1.Ask the pt to squeeze both of your hands, offering Vocal stimuli
index & middle fingers. If the pt’s eye are closed, you Responds to Pain P
may lightly touch his hands to let him know where Unresponsive U
your fingers are, but do not put your fingers into his
hands or you may elicit a reflex grasp (not released 2.BEHAVIOUR
when the pt is asked to do so).
2.If the pt is able to squeeze your hands with one or -Co-operative
both of his hands, record: Obeys command. If not,
apply sternal rub (with your knuckles). If the pt’s arm
3.EXPRESSION/APPEARANCE
reaches upto the site of the painful stimulation,
record: Localises pain. If the pt’s arm does not localize
-Pleasant/ Disturbed/ Apathetic/ Agitated/ Confused
the site of the pain, then apply nail bed pressure to
one finger. Now if the pt’s arm withdraws from the
source of the pain, then record: Withdraws to pain, if >Do not tell in the examination unless asked.
the pt’s arm abnormally flexes record: Abnormal
flexion, if the pt’s arm extends record: Extension & if 4.ORIENTATION WITH TIME, PLACE &
the pt’s arm makes no movement at all, record: None. PERSON
Test both arms, but record only best response.
Abnormal flexion consists of adduction at the -Well oriented/ Disoriented
shoulders, flexion at the elbows, pronation of the
forearms and flexion of the wrist & fingers. a.TIME
COMA SCORE=E+M+V Ask the pt to estimates approximate time without

looking at watch. Now it is day or night?
>GCS is useful in assessing the level of consciousness in
a pt with head injury. b.PLACE
>Severe head injury is stated to be present if score is ≤
7 (i.e 7 or < 7) & persists for > 6 hours. Ask the pt about where where he is now.
>Scores < 4 indicates coma, scores 4 to 9 indicates
c.PERSON
stupor & scores > 9 excludes coma. Scores > 11 indicate
5-10% chance of death while scores 3 or 4 indicate 85% Ask the pt to recognize his family members or to
chance of dying. identity of his nearby relatives or neighbours
>According to GCS, coma is defined as not opening
eyes, not obeying commands & not uttering d.SELF
understandable words.
>Less than or equal to 8 are in coma. Greater than or Ask the pt’s name, age, address & qualifications.
equal to 9 are not in coma. 8 IS THE CRITICAL SCORE.
5.MEMORY
INTERPRETATION SCORE -Intact

Best total score 15 Ask about those things which you know & the pt is also
Mild injury 13 to 15 expected to know.
Moderate injury 9 to 12
a.IMMEDIATE MEMORY (=WORKING MEMORY)
Severe injury ≤8
It can be tested by saying a list of 3 items & then asking
INTERPRETATION SCORE the pt to repeat the list immediately. Ask the pt to count
Maximum score 15 backwards from 7 to 1.
Minimum score 3
Fully conscious 15 b.RECENT MEMORY (=SHORT TERM MEMORY
Deeply comatose 3 =EPISODIC MEMORY)
>All pts in coma should be asked to open their eyes & Ask the patient about-
look up & down, because in locked-in syndrome, only • Day of the week?
these movements are spared. • Name of the month?
(-Others:-
• Date of the month?
• Ask the pt to recall what he read in newspaper
yesterday or seen on television yesterday?/ Ask
47
about things happened in past 3-4 days. probably we are dealing with a case of snsory aphasia or
• Ask the pt to repeat the days of the week global aphasia.
backwards or to spell INDIA backwards. APHASIA
• Who examined the pt earlier in the day ?
• Give the pt a telephone number & ask the the Defect in higher center with difficulty in language
number after a minute or so). function. It is of following types-
c.REMOTE MEMORY (=LONGTERM MEMORY=PAST a.MOTOR APHASIA (= BROCA’S APHASIA =

MEMORY) EXPRESSIVE APHASIA)
You should ask about the things in which the pt is Pt is unable to speak although there is no paralysis of
interested & the things that everybody knows like- faciolingual muscles. Motor ahasia means pt will not talk
• Name the recent festivals observed. whatever you do.
(-Others:-
• When was the supercyclone occurred in Orssa? b.SENSORY APHASIA (=WERNICKE’S APHASIA =
• When was the tsunami occurred in India? RECEPTIVE APHASIA)
• Ask him the date of Independence Day of India.
• Who was the first prime minister of India? It is of following types
• Who won the cricket world cup in 1983?)
1.WORD DEAFNESS
6.INTELLIGENCE
Though the pt can hear the sound, he is unable to
analyse its meaning & so can not speak.
-Normal
>Intelligence is the total assessment of judgement, 2.WORD BLINDNESS
reasoning, arithematic ability etc. & is tested by-
a.Calculation ability by serial 7-substraction test i.e The pt can see that something is written, but he can
serial substraction of 7 from 100-100,93,86,79,72,…… not recognize the words. His mother language appears
or serial substraction of 3 from 20. to be a foreign language to him.
b.Ask the pt about what he will do if he sees a house on
fire or a stampede & addressed envelope lying on the c.GLOBAL APHASIA
road in front of his house.
c.Insight-Observe his awareness about the illness for This is a combination of sensory & motor aphasia i.e
which he has been admitted. there is defective comprehension as well as production
d.Reasoning-Can he tell the difference between poverty of speech.
& dishonesty, child & dwarf etc.
e.Abstract thinking-Ask him the meaning of proverbs DYSARTHRIA
like all that glitters is not gold etc.
f.Attention-It is tested by tapping the finger with Defect in articulation due to neuromuscular or muscular
repetition of a particular number. disorders resulting in impaired coordination faciolingual
muscles.
7.SLEEP
DYSPHONIA
-Adequate/ Inadequate
Disorder of phonation due to abnormality of vocal cord.
8.SPEECH Know in detail about aphasia.
-Normal 9.GAIT
A.APHASIA (Dysphasia)-Sensory/ Motor/ Global -Normal/ Hemiplegic gait/ Could not be tested
B.DYSARTHRIA-
HEMIPLEGIC GAIT (SPASTIC GAIT)
-Cortical/ Cerebellar/ Bulbar/ Pseudobulbar
This is seen in hemiplegic pts after recovery. The pt
C.DYSPHONIA walks on a narrow base. The hemiplegic limb is held
stiffly and does not flex at the knee & hip. While the pt
EXAMINATION OF APHASIC PATIENT drags his foot, the foot is raised from the ground by
tilting the pelvis to the healthy side & the leg is swung
Ask the pt his name. If he keeps mum, now write “show forward forming a semicircle or an arc known as
your tongue” on a white paper & show the paper to the circumduction of the leg. The outer side of the sole of
Pt. If he protrudes his tongue, then it is a case of motor the shoe is worn (as there is plantiflexion on the
aphasia (i.e comprehension is perfect & word blindness affected side). The affected arm is adducted at the
is not present). If he does not protrude the tongue, shoulder & flexed at the elbow, wrist and fingers & does
not swing naturally. The hemiplegic gait is essentially a
plastic gait.
48
tested by the Snellen’s chart as done in the eye
>HOOVER’S SIGN-It is a sign of hysterical paraplegia. department.
The patient lies supine & is asked to raise one leg
against resistance.In a normal person, the back of the 2.NEAR VISION
heel of the contralateral leg is pressed firmly down in
the bed (examiner’s hand is placed under the heel), and One eye is tested at a time (Other eye is closed by the
the same is true in a patient with organic hemiplegia hollow of the palm). Ask the pt to count the fingers of
when he tries to lift the paralysed or weak leg against the examiner’s hand held in front of him or to read
resistance.This is absent in hysteria. newspaper. If finger counting is not possible, put torch
light on the eye & examine for PL (Perception of light)/
10.HANDEDNESS PR (Projection of rays). pt should wear the spectacles
during the bedside test.
-Righthanded/ Lefthanded/ Ambidextrous
b.VISUAL FIELD BY CONFRONTATION TEST
Give something instantaneously (i.e before the pt is (CONFRONTATION PERIMETRY)
prepared for anything) to catch hold & see in which
hand he first picks up the thing. -Same as that of you/ Restricted_________quadrant
>Typical description-HIGHER FUNCTIONS ARE Sit in front of the pt at adistance of 1 METRE at the
NORMAL OR HIGHER FUNCTIONS COULD NOT BE TESTED same level. To test the field in the rt eye, ask the pt to
BECAUSE OF ALTERED SENSORIUM. cover the lt eye with the hollow of his lt palm & to look
steadily at your lt eye. Cover your rt eye with the hollow
II.CRANIAL NERVES of your rt hand & gaze steadily at the pt’s right eye. The
pt should not move his head. Hold up the index finger of
>Cranial nerves are teted only when the pt is fully your lt hand in a plane midway between the pt’s face &
conscious,except 7th and 3rd, 4th & 6th cranial nerves your face (at first) almost a full arm’s length to the side
which can be tested even if the pt is unconscious or the (i.e periphery). Keep moving your finger & bring it
pt has altered sensorium. nearer to the midline until you first perceive the moving
>Test in both sides-Rt & lt. finger. Ask the pt to say when he first sees the
>The bare minimum for cranial nerve examination- movement of the finger, making sure all the time that
he steadily fixes gaze at your eye. If the pt fails to see
Check visual fields, pupil size & reactivity, extraocular
the finger, keep moving it nearer till the pt sees it. Test
movements, and facial movements.
the four quadrants of the field in EACH EYE SEPARATELY
by moving finger upward, downward, to rt & to lt, using
1.OLFACTORY NERVE
the extent of your own field for comparision. Preferably
remove both the examiner’s & the pt’s spectacles (if
Precautions-
any) prior to testing field by confrontation method.
1.Exclude local changes like nasal catarrh.
(First test the acuity of vision.)
2.Examine each nostril separately.
>In a non-cooperative pt, a shiny object is moved from
3.Pt’s eyes are clo9sed during the test.
the periphery to the centre & one has to ascertain
4.Avoid irritating substances like ammonia (as they
whether the pt is able to see it OR move your hand
stimulate the trigeminal nerve).
quickly towards pt’s face & observe the reflex blinking of
>Ideal objects (non-irritating substances) for olfaction
both the eyes (MENACE REFLEX) as confrontation
are oil of peppermint, oil of cloves, tincture of asafoetida
method is not possible here. This method can also be
or oil of lemon. But in the exam, the students should
applied in a pt who is unable to sit on the bed.
test olfaction by common bedside substances like soap,
toothpaste, fruits etc.
c.COLOR VISION
ADVICE-No need to test this nerve in the exam & -Pt can distinguish red, green & orange color/ can’t
hence no need to take materials needed to test this
nerve. But you should know in detail about how to test
>Roughly, color vision is assessed by asking the pt to
this nerve & what are the abnormalities of this nerve
tell the color of his shirt or pant, room wall, ceiling fan,
caused by different diseases & the olfactory pathways of
bedsheet etc.
sensation whcih can be asked in the exam.
ADVICE-No need to test for color vision in the exam &
2.OPTIC NERVE
hence no need to take materials needed to test color
vision. But you should know in detail about how to test
a.VISUAL ACUITY color vision & what are the abnormalities of color vision
caused by different diseases, which can be asked by the
1.DISTANT VISION examiner.
One eye is tested at a time (Other eye is closed by the 3.III, IV & VI NERVE (IMPORTANT)
hollow of the palm). Ask the pt to count the beams in
the ceiling or blades in the fan or to read what is written
All these three nerves are tested simultaneously.
in the wall of ward. Ideally distant vision should be
49
A.PTOSIS C.EXAMINATION OF PUPIL
-Present/ Absent 1.SIZE _____mm

>Ptosis means drooping of upper eyelid, where the
drooped upper eyelid covers the pupil. But in a normal METHOD TO DETERMINE THE SIZE OF THE PUPIL
individual, the upper eyelid covers only part of the
upper part of the cornea but not the pupil. Pt lies supine in bed. Hold your torch light parallel to the
bed & then put light on the examining eye in such a way
TESTS FOR PTOSIS that light beam falls tangentially on the eye. See the the
(Method to test the power of the LPS muscle of the pupil & note its size (Take an approximate
upper eyelid)- measurement). If you put light vertically on the eye, the
pupil will contract & you can not determine the actual
1. FIRST STEP size of the pupil. That is why light is thrown tangentially
on the eye to determine the pupil size.
Stand in front of the pt face to face & ask him to look
upwards or elevate the upper eyelid voluntarily. >The size of the normal pupil varies between 3-5 mm. If
< 3mm, it is called miosis & if > 5mm, it is called
2. SECOND STEP mydriasis. Normally, pupils are circular & regular in
outline, and equal in size. PINPOINT PUPIL is 1 mm OR
Now push down the frontal belly of occipitofrontalis LESS in diameter.
muscle of forehead by your lt hand (it is done to
eliminate the elevating action of the occipitofrontalis on 2.SHAPE
the upper eyelid). Again ask the pt to look upwards.
-Circular/ Pinpoint/ Vertically oval
3. THIRD STEP
METHOD TO DETERMINE THE SHAPE OF THE PUPIL
If the pt can elevate the upper eyelid, now you may
apply little resistance by your rt index finger over the Hold your torch light parallel to the ground & then put
upper eyelid & ask the pt to look upwards again. light on the examining eye in such a way that light
Compare with the other side again. beam falls tangentially on the eye. See the pupil & note
its shape.
4.If the pt can not elevate the uooer eyelid voluntarily,
it is useless to do the next steps. >Pinpoint pupil is seen in organophousphorous
poisoning, opium poisoning, pontine hemorrhage,
B.OCULAR MOVEMENTS carbolic acid poisoning etc.
-Normal/ Restricted in particular direction 3. LIGHT REFLEX (=PUPILLARY LIGHT REFLEX =

PUPILLARY REFLEX =REACTION TO LIGHT)
>REMEMBER THAT THE RECTI MUSCLES ARE ELEVATORS
& DEPRESSORS ALONE WHEN THE EYE IS IN ABDUCTION - Reacting (R)/ Sluggish (S)/ None (N)/ Eye closed (C)
(LATERALLY) & OBLIQUE MUSCLES ACT SIMILARLY
WHEN THE EYE IS IN ADDUCTION (MEDIALLY).
>Both optic & occulomotor nerves are tested by light
reflex.
>Both eyes open, pt’s head in neutral position, pt fixes
his gaze on examiner’s index finger & reports if double a.DIRECT LIGHT REFLEX
vision occurs while following the movement of the finger
held at 60 cm away. The pt is instructed to follow the -Intact/ Abolished (Lost)
moving finger with his eyes & not to move his head.
Move the finger- Pt is asked to look straightforward at a distant object &
1.Above his head in the midline-SR & IO of both eyes. the light is thrown suddenly from the periphery (to
2.Below his head (finger kept at the level of his chest)avoid accommodation reflex) & then the light is taken
in the midline-IR & SO of both eyes. back immediately. The pupil constricts promptly. For
3.Laterally to the lt-LR of lt eye & MR of rt eye direct light reflex, the non-testing eye should be closed
4.Laterally to the rt-MR of lt eye & LR of rt eye by the hollow of the other palm. Each eye is tested
5.Above his head but placed laterally-SR of same separately. Direct light reflex should be tested
side (lateral side) eye & IO of opposite eye preferably in a dark room. Pencil torch with good power
6.Below his head but placed laterally-IR of same side of illumination is used. Constriction of pupil to which the
(lateral side) eye & SO of opposite eye light shown is called direct light reflex & constriction of
7.Straight ahead-All extra ocular muscle the other pupil is called consensual light reflex. For
direct light reflex, afferent is optic N of the same side &
>Check whether the pt describes diplopia in any efferent is occulomotor N of the same side. Light reflex
direction of gaze. True diplopia almost always resolves is consensual i.e the light information from onre eye
with one eye closed. reaches the brainstem via optic N & returns to both eyes
through occulomotor N of their respective sides causing

50
both pupils to constrict. Light reflex is a brainstem D.STRABISMUS
mediated reflex since the efferent pathway consists of
fibres arising from Edinger-Westphal nucleus situated in >Look for lateral rectus palsy due to 6th nerve palsy in
the midbrain & these fibres are carried along the hemiplegia or due to raised intracranial pressure.
occulomotor N. Since light reflex is a brainstem reflex, >Tell in the exanination only when you are asked.
cortical lesions don’t abolish it i.e light reflex is intact in
Otherwise do not tell. But you have to know in detail
cortical blindness & is not abolished in cortical blindness.
about this so that you can answer if you are asked in
the examination.
b.CONSENSUAL LIGHT REFLEX
(=INDIRECT LIGHT REFLEX)
E.NYSTAGMUS
-Intact/ Abolished (Lost)
Tell in the exam only when you are asked. Otherwise do
Pt is asked to look straightforward at a distant object & not tell. But you have to know in detail about this so
the light is thrown suddenly from the periphery (to that you can answer if you are asked in the exam.
avoid accommodation reflex). Place your hand with
ulnar border resting on nose like a curtain to avoid F.DIPLOPIA
spillage of light to the other eye. Both the eyes are kept
open. When light falls on one eye, observe the pupilary 1.Monocular
constriction of the other eye. Each eye is tested 2.Binocular-Homonymous/ Heteronymous
separately. For consensual light reflex, afferent is optic
N of the other side & efferent is occulomotor N of the Tell in the exam only when you are asked. Otherwise do
same side. not tell. But you have to know in detail about this so
that you can answer if you are asked in the exam.
>You can test both direct & indirect light relexes 4.TRIGEMINAL NERVE (IMPORTANT)
simultaneously by keeping ulnar border of the lt hand
on the nasal bridge (to avoid spillage of light to opposite A.SENSORY FUNCTION
eye) & the light is thrown suddenly from the periphery
by holding a torch in the rt hand & the light is then -Intact/ Lost
taken back immediately. Look at the eye on which light
falls for direct light reaction & the opposite eye for Ask the pt to close his eyes. Check the light touch
consensual light reaction. sensation with a wisp of cotton in the territories supplied
by each division of trigeminal nerve independently,
c.SWINGING LIGHT REFLEX comparing rt with the lt. Also test for pain &
temperature.
Do not tell in the exam. No need to test this swinging
light reflex in the examination. But you should know in 1.OPHTHALMIC DIVISION
detail about how to test for swinging light reflex & what
are the abnormalities of swinging light reflex caused by Supplies skin of upper eyelid, forehead, scalp as far as
different diseases. vertex & medial part of the skin of the nose upto
nosetip. Tip of the nose
d.RELATIVE AFFERENT PUPILLARY DEFECT
2.MAXILLARY DIVISION
4.ACCOMODATION REFLEX
Supplies skin of lower eyelid, upper lip, upper cheek
(Malar areas) & adjacent areas of nose, anterior part of
-Intact/Lost
the temple. Sides & alae of the nose
The pt is asked to look at a distant object. Then ask him
to look at your finger which is gradually moved toward 3.MANDIBULAR DIVISION
the bridge of the nose & observe for miosis (Bilateral) &
convergence of eyeball. Supplies skin of lower part of the face, lower lip, lower
jaw except over angle, upper 2/3rd of lateral surface of
5.CILIOSPINAL REFLEX the auricle, temporal area, sides of the head.
-Intact/Lost B.MOTOR FUNCTION
Dilation of the normal pupil when the skin of the neck is -Intact/ Lost
pinched. It is due to reflex excitation of the pupil-
dilating fibres in the cervical sympathetic. The response 1.Note the symmetry of the temporal fossa i.e
is abolished by lesions of the cervical sympathetic & suprazygomatic region & the angle of the jaw to note
sometimes by medullary, cervical & upper thoracic the bulk of the temporalis & masseter respectively.
spinal cord lesion. Do not tell about the cliospinal reflex Paralysis of the temporalis & masseter results in
in the exam, but you must know in detail abot this hollowing of the temporal fossa & flattening of the
reflex so that you can answer if at all you are asked. angle of the jaw respectively.

51
2.Ask the pt to clench his teeth. Then inspect & palpate afferent is trigeminal nerve & the efferent is facial
the masseter at the angle of the mandible & nerve.
temporalis above the zygoma on both sides &
estimate their bulk & symmetry. Paralysed muscle will 5.FACIAL NERVE (IMPORTANT)
be less prominent while active muscle stands out.
3.Test for both medial & lateral pterygoid, myelohyoid & CORTICAL CONNECTIONS OF CRANIAL NERVE NUCLEI
anterior belly of diagastric by asking the pt to open his
mouth against resistance applied at chin by the All cranial nerve nuclei are under cortical control
examiner. through corticonuclear fibres i.e pyramidal tract fibres.
4.Lateral pterygoids are also tested by asking the pt to All the cranial nerve nuclei receive bilateral pyramidal
open his mouth & to move the lower jaw from side to tract supply except the lower part of the 7th cranial
side against the examiner’s resistance. Weakness of nerve nuclei which receive pyramidal fibres from the
the pterygoids causes the jaw to deviate towards the opposite side i.e from opposite cerebral hemisphere.
paralysed side on opening the mouth due to the action Cortical control of hypoglossal nucleus is contralateral
of the normal pterygoids. i.e from opposite cerebral hemisphere. The trochlear
nucleus receives ipsilateral fibres i.e from the same side
C.CORNEAL REFLEX (=LID REFLEX) cerebral hemisphere, but the LMN from the trochlear
nucleus cross to the opposite side & innervate the
-Intact/ Impaired/ Lost opposite eye i.e the trochlear nerve decussates &
crosses to the opposite side before innervating its target
Ask the pt to look medially. Then approach from the superior rectus muscle. So in case of ipsilateral cortical
lateral aspect of the eye & very lightly touch the cornea lesion, the contralateral eye is affected. All other nuclei
at its conjuctival margin with a wisp of damp (moist) are influenced by both cerebral hemispheres but the
cotton wool which is twisted into a fine hair. If the reflex fibres to the abducent nerve are predominantly crossed.
is present, there will be simultaneous closure of both
the eyes. Closure of the test side eyelid is called direct CORTICAL CONNECTIONS OF FACIAL NERVE NUCLEI
corneal reflex while closure of the eyelid of the
nontesting eye is called consensual corneal reflex. Both There are two Facial nerve nuclei- one on the rt side &
the eyes should be tested one after another. The cornea one on the lt side. Each Facial nerve nucleus has two
is stimulated from the side to avoid menace reflex parts-Upper part & Lower part. Pyramidal tract fibres to
(Reflex closure of the eyes if an object is brought to the the upper part of the Facial nerve nucleus on each side
pt directly from the front). Avoid touching the come from both cerebral hemispheres i.e upper part of
eyelashes. If the pt is apprehensive, then first touch the the Facial nerve nucleus has bilateral pyramidal tract
conjunctiva to allay his fear & then touch cornea. supply. But pyramidal tract fibres to the lower part of
the Facial nerve nucleus on each side come from
>In the absence of cotton, blowing a puff of air into contralateral cerebral hemisphere only i.e lower part of
each cornea will serve the purpose. This reflex is also the Facial nerve nucleus has unilateral & contralateral
called CONJUNCTIVAL REFLEX. pyramidal tract supply. Lower motor neuron from the
>Corneal Reflex: Afferent-V1 i.e Ophthalmic upper part of the Facial nerve nucleus supplies the
division of Trigeminal nerve, Efferent-Facial (VII) muscles of the ipsilateral upper part of the face & lower
nerve motor neuron from the lower part of the Facial nerve
>Frequent use of contact lenses abolishes this reflex. nucleus supplies the muscles of the ipsilateral lower part
of the face. Hence, in Hemiplegia, the contralateral
>Failure of the either side of the face to contract-V1
lower part of the face is affected which has only
lesion. Failure of only one side to contract-VII leson.
unilateral & contralateral pyramidal fibres supply while
Absent corneal reflex can be an early & objective sign of
the upper part of the face escapes which has bilateral
sensory trigeminal lesion.
pyramidal fibres supply.
D.JAW JERK (Pons)
A.INSPECTION
-Intact/ Impaired/ Lost
EFFECTS OF FACIAL NERVE PARALYSIS
Ask the pt to open the mouth partially. Then place your
>The affected side of the face loses its expression. The
lt index finger in the groove under the lower lip. Tap the
index finger in a downwards with polnted end of the nasolabial fold is less pronounced. The furrows of the
knee hammer. The normal response is slight & consists brow are smoothened out. The eye is more widely open
of sudden closure of the mouth. This reflex is sometimes than the other and mouth is drawn towards the healthy
absent in health. The jaw jerk is increased in UMN side. The food collects between the teeth and gum. The
lesions above the 5th cranial nerve nucleus, e.g in saliva and any fluid the pt drinks escape from the
pseudobulbar palsy or multiple sclerosis. affected angle of the mouth. There is loss of salivation &
loss of lacrimation.
E.BLINK REFLEX=GLABELLAR REFLEX= ORBICULA- >Look for upper part of the face-Involved/ Escaped.
RIS OCULI REFLEX Observe the face for any asymmetry, epiphora,
flattened nasolabial fold (Nasolabial Fold-Intact/
Percussion over the supraorbital ridge results in bilateral Flattened) & deviation of angle of mouth to one side.
contraction of the orbicularis oculi muscle. Here, the Observe the symmetry of blinking & eye closure,
52
presence of any tics or spasms of the facial muscle & >IN UNCONSCIOUS PATIENT, 7th CRANIAL NERVE & 3rd,
spontaneous movements of the face, particularly the 4TH & 6TH CRANIAL NERVES (TESTED BY
upper & lower facial muscles during actions such as OCULOCEPHALIC REFLEX) CAN BE TESTED.
smiling. C.TASTE SENSATION OF ANTERIOR 2/3 OF TONGUE
B.MOTOR FUNCTION -Intact/ Impaired/ Lost
1.FOREHEAD FURROWING (OR EYEBROW RAISING) >Usually not tested in the final MBBS practical exam. &
there is no need to take sugar, quinine tablets etc. to
Ask the pt to wrinkle his forehead or ask him to look at the exam. Tell only if you have tested it. Otherwise tell-
your index finger which is placed above his head after Taste sensation is not tested.
keeping his head fixed-Tests frontal belly of >1.Sugar solution 2.Salt solution 3.Sour solution
occipitofrontalis
4.Bitter solution
>Ask the pt to close his eyes & open the mouth first.
2.EYE CLOSURE
Then pull out the tongue with a gauze piece. Then test
samples are put on the tongue one by one & each time
Ask pt to close both eyes forcibly while you try to open
mouth is washed & then only a new sample is put.
the eyelids by your fingers (both eyes must be
Bitter sample is tested at last. Don’t move the tongue
examined for comparision) -Tests orbicularis oculi
inside. Pt should not talk. Ask the pt to identify the
sample (Pt should interpret the result) by pointing to
3.FROWNING
the written test card).
Ask the pt to frown-Tests corrugator superciliaris >Sensations perceived by the tongue are sweet at tip,
our at margins, bitter at the back & salt by any part of
4.TEETH SHOWING the tongue.
Ask the pt to show his upper teeth-Tests levator angulis 6.VESTIBULOCOCHLEAR NERVE
oris, zygomatic major & minor, depressor anguli oris,
buccinator & risorius A.HEARING TEST-TUNING FORK OF 256 HZ
5.WHISTLING 1.WEBER TEST

2.RINNE’S TEST
Ask the Pt. to whistle. Ask the pt to purse his lips-Tests
orbicularis oris & buccinators.
>Usually not tested. But you have to know detail about
all the tuning fork tests along with their interpretation
so that you can answer when asked in the examination.
6.CHEEK BLOWING OUT >Tuning fork is essential for the final MBBS practical
exam to demonstrate Weber’s test, Rinnie’s test &
Ask the pt to blow out his cheek or purse his lips-Tests vibration sensation.
only orbicularis oris
B.OCULOCEPHALIC REFLEX
(=DOLL’S EYE MOVEMENTS= DOLL’S HEAD MOVEMENTS)
7.PLATYSMA
Ask the pt to retract & depress the angle of mouth.While Stand on the head end of the bed. Grasp the pt’s head
doing this, folds of platysma may be seen. with both hands, using the thumbs to hold the upper
eyelids open gently, and firmly rotate the pt’s head from
side to side through 700, and then from passive neck
>Facial nerve supplies all the muscles of the face & scalp
flexion to passive neck extension. Observe the motion of
except the levator palpebrae superioris (LPS). the eyes. The pt’s eyes tend to remain in the straight
>In unconscious pt, give painful stimuli by pressing ahead position despite these passive movements of the
upward the medial side of the orbit above the medial head, a phenomenonlike that found in some children’s
canthus (i.e medial aspect of the upper margin of the dolls i.e the pt’s eyes tend to deviate in he opposite
orbit) of two sides simultaneously. Look for facial direction to the induced movement. This doll’s head
grimacing & facial muscle paralysis. ocular movement depends on intact vestibular reflex
>There may be apparent deviation of the tongue to the mechanisms & is thus a test of the peripheral sense
healthy side on protrusion. organs like labyrinths & otoliths, and their central
connections in the brainstem, including the vetibular
METHOD TO TEST FACIAL MUSCLES TONE IN nuclei, the medial longitudinal fasciculi & the efferent
HEMIPLEGIA pathway through oculomotor, trochlear & abducent
nerves & their nuclei. So lesions in these structures can
Turn the Pt. to one side & observe for dribbling of the
be recognized during doll’s head test by the presence of
saliva from the corners of the mouth. There will be
disturbances in ocular movements. Disturbances in
hypotonia of facial muscles of that side from which ocular movements in oculocephalic reflex are found in
saliva dribbles down from the mouth.
abducent nerve palsy, oculomotor nerve palsy, lesions

53
of brainstem, deep metabolic comaetc. In most pts with loss of the explosive phase of the normal coughing due
drug-induced coma, doll’s head ocular movements are to failure of the vocal cords to close the glottis.
intact.
D.GAG REFLEX
7.GLOSSOPHARYNGEAL NERVE
Touch the posterior wall of pharynx on each sideone
Usually not tested.
after another with a piece of cotton wrapped on a
broomstick & note its reflex contraction.
A.PHARYNGEAL REFLEX (=GAG REFLEX)
INTERPRETATION
-Bilateral normal response/ Absent in rt or lt side
1.Normally, there is bilaterally symmetrical contraction
B.TASTE SENSATION OF POSTERIOR 1/3 OF TONGUE of pharynx. The reflex is normally absent in normal
individuals.
-Intact/ Lost 2.This reflex is absent on the side of the lesion of the
9th & 10th cranial nerves (LMN type of palsy).
8.VAGUS NERVE 3.Exaggerated gag reflex is seen in pseudobulbar palsy
(UMN type of palsy).
A.PALATAL REFLEX (PALATAL MOVEMENT) 4.If on eliciting the gag reflex, the pt is able to feel the
tickling sensation, but there is no reflex contraction of
The pt is placed facing the light with his mouth open (A the pharynx, then only the 10th cranial nervre may be
tongue depressor is introduced for the better affected & that the 9th cranial nerve is intact.
visualization of the palete). The position of the soft However, it is very rare to see this type of lesion
palate on both sides and that of the uvula are noted. (involvement of the 10th & sparing of the 9th cranial
Then ask the pt to say AAH. Observe the elevation of nerve) clinically.
the soft palate on both sides & the elevation of the
uvula. >Afferent-Glossopharyngeal (IX) nerve, Efferent-
Vagus (X) nerve
UNILATERAL PALATAL PARALYSIS
9.SPINAL ACCESSORY NERVE
The palatal arch on the affected side is at a lower level
than on the healthy side. On saying AAH, the uvula is -Intact/ Paralysed-Lt/ Rt
pulled to the healthy side by the normal palate. There is
little or no movement of the affected palate i.e the A.TEST FOR STERNOMASTOID
affected side palate fails to rise as in normal case.
1.INDIVIDUAL STERNOMASTOID
BILATERAL PALATAL PARALYSIS Stand in front of the pt. Test the lt sternomastoid by
asking the pt to rotate the head to the rt side against
Whole soft palate remains motionless on both sides. the examiner’s resistance offered by placing his hand
against the rt side of the chin & viceversa. Compare
>Observe the position & symmetry of the palate and both the sides. In a normal person, the sternomastoid
uvula at rest & with phonation. In a normal case, there muscle on the side opposite to the direction of the head
is bilateral equal movement. movement stands out prominently.
2.BOTH STERNOMASTOIDS
B.HOARSENESS OF VOICE
Ask the pt to press the chin downwards with mouth
-Present/ Absent closed against the examiner’s resistance. Both the
sternomastoids will become prominent which can be
Ask the pt his name or address & observe for the corroborated by both inspection & palpation of the
hoarseness of voice. muscles. In bilateral paralysis of the sternomastoid
muscles, head tends to fall back.
C.COUGH
B.TEST FOR TRAPEZIUS
-Normal/ More nasal OR Bovine (i.e explosive nature of
the cough is lost) Stand behind the pt. Ask the pt to elevate his shoulders
Ask the pt to cough for the demonstration of bovine against the downward pressure applied on his shoulders
cough. by the examiner while standing behind the pt. First
demonstrate elevation of shoulders to the pt & then
BOVINE COUGH press both the shoulders down from behind.
A characteristic feature of organic laryngeal paralysis is 10.HYPOGLOSSAL NERVE

cow-like cough i.e bovine cough which results from the
-Intact/ Paralysed-Lt/ Rt

54
3.MID THIGH CIRCUMFERENCE-18 cm above the
1.While the tongue is within the oral cavity, observe for superior border of the patella
wasting & fasciculation. 4.MID LEG CIRCUMFERENCE-10 cm below the tibial
2.Ask the pt to protrude his tongue as far as possible & tuberosity
look for any deviation & tremor. The pt may not be (Examine big muscles like biceps, quadriceps plus small
able to protrude the tongue much beyond the teeth in muscles of the hand & foot.)
presence of paralysis. >Note the distribution of the nutritional change i.e
3.Ask the pt for in & out movement of tongue, lick the predominantly proximal or distal or both proximal &
each tooth with tongue. distal.
4.Press against the tongue from outside when the pt is
asked to press the tongue against the cheek & feel for 2.TONE OF THE MUSCLE
the strength of contraction.
5.Assess hypokinesia by asking the pt to say lah, lah, -Tone of the muscles around___joint is-Normal/ Hypoto-
and lah as quickly as possible & to make rapid in & nic/ Hypertonic-Spasticity or Rigidity
out, & side-to-side movements of the tongue.
6.In 12th nerve paralysis, tongue deviates to the side of METHODS TO ASSES THE MUSCLE TONE
paralysis on protusion due to unopposed action of the
normal genioglossus. The pt may not be able to 1. CLASSICAL METHOD
protrude the tongue much beyond the teeth.
Muscle tone is tested by measuring the resistance to
> TYPICAL DESCRIPTION-ALL THE CRANIAL NERVES ARE passive movement of a relaxed limb. Pts often have
INTACT. difficulty in relaxing during this procedure, so it is useful
to distract the pt to minimize active movements. Ask
the Pt. to relax & go flabby. Passively flex & extend each
III.MOTOR FUNCTION joint, do this slowly at first & then more rapidly to get a
feel of muscle tension. Always compare with the
-Tested in upper limb, lower limb & trunk both in the rt opposite side while assessing the tone. Pt must be fully
& lt side. relaxed while assessing the tone.
1.BULK OF THE MUSCLE " UPPER LIMB

(=NUTRIRION OF THE MUSCLE)
Test tone in the shoulder, elbow & wrist joint. In the
upper limbs, tone is assessed by rapid pronation &
-Normal/ Atrophy or Wasting/ Hypertrophy
supination of the forearm & flexion & extension at the
wrist.
NUTRITION OF MUSCLE IS ASSESSED BY
" LOWER LIMB
A.INSPECTION
Test tone in the hip knee & ankle joint. In the lower
Inspect for atrophy or wasting of the muscle, flattening limbs, while the pt lies supine, the examiners hands
of overlying skin or hollowness over the area, prominent are placed behind the knees & rapidly raised. With
knuckles or bony prominences, prominent interosseous normal tone, the ankles drag along the bed surface for
gutters in hand or foot, prominent extensor or flexor a variable distance before rising, whereas increased
tendons in hand or foot. tone results in an immediate lift of the heel off the
surface.
B.PALPATION
2. ATTITUDE OF THE PT
Normal muscle feels elastic. Atrophied muscles are
small, soft & flabby on palpation. By seeing the attitude or decubitus, one can say that
the flexor tone is increased in the upper extremity &
C.MEASUREMENT extensor tone is increased in the lower extremity on the
affected side of the hemiplegic pt.
Measure the girth of the specific muscle by a measuring
tape from a fixed bony point & compare it with the other 3.Hypotonic muscles are abnormally soft to palpation.
side. For the upper limb the fixed bony point is the 4.If a limb falls like a log of wood when lifted up &
olecranon process of the elbow & for the lower limb it is realeased i.e it behaves as if the limb doesn’t belong
the tibial tuberosity. The difference in the circumference to the pt, then hypotonia is diagnosed.
(comparing with the opposite side) will give objective 5.Ask the pt to outstretch the upper limbs & spread the
evidence of wasting or hypertrophy. Measure the fingers. Then the hypotonic limb may assume an
following circumferences- abnormal posture i.e hyperextended at elbow,
hyperpronated at forearm, flexed at wrist &
1.MID UPPERARM CIRCUMFERENCE:10 cm above the
hyperextended at fingers at metacarpophalangeal
olecranon
joints which is known as dinnerfork deformity.
2.MID FOREARM CIRCUMFERENCE:10 cm below the
olecranon

55
a.HYPERTONIA METHOD OF TESTING THE TONE OF THE FACIAL
MUSCLES IN HEMIPLEGIA
>Muscles feel stiff & there is diminished range of passive
movement. Turn the pt to one side & observe for dribbling of the
>Hypertonia is of 3 types-spasticity (pyramidal tract saliva from the corners of the mouth. There will be
hypotonia of facial muscles of that side from which
lesion), rigidity (extrapyramidal tract lesion) & paratonia
saliva dribbles down from the mouth.
or gaganhalten.
1.SPASTICITY >Decreased tone is most commonly due to LMN or

peripheral nerve disorders. Increased tone may be
1.Always seen in UMN lesion & it takes sometime for evident as spasticity (resistance determined by the
the spasticity to develop angle & velocity of motion-Corticospinal tract disease),
2.Tone is of clasp-knife in type i.e hypertonia is felt rigidity (similar resistance in all angles of motion-
maximally at the beginning or at the end of passive Extrapyramidal disease), or paratonia (fluctuating
movement. There is initial resistance to movement changes in resistance-Frontal lobe pathways or normal
followed by no resistance. difficulty in relaxing). Cogwheel rigidity, in which
3.Hypertonia is marked in flexor muscles of upper passive motion elicits jerky interruptions in resistance, is
limbs & extensor muscles of lower limbs i.e in seen in Parkinsonism.
antigravity muscles.
4.Usually associated with brisk tendon reflexes, 3.POWER OF THE MUSCLE (STRENGTH OF THE
clonus, positive Babinski’s sign & classical pattern of MUSCLE)
weaknesss.
5.Involuntary movements are not seen. A.Power in the upper limb is___grade
B.Power in the lower limb is___grade
2.RIGIDITY
PREREQUISITE
1.Seen in extrapyramidal lesion.
2.Tone is of lead pipe or cogwheel in type While testing power of the muscles, expose the muscle
fully. Ask the pt to contract the muscle against your
1.LEAD PIPE RIGIDITY resistance. See the muscles contracting. Feel the
strength of contraction & compare with your own
Uniform resitance is felt throughout the entire range strength or what you judge to be normal.
of passive movement as if bending a lead pipe.
THERE ARE TWO METHODS TO TEST MUSCLE POWER
Found in lower limb & trunk in Parkinsonism.
1.ISOMETRIC TESTING (i.e MUSCLE LENGTH CONSTANT)
2.COGWHEEL RIGIDITY
The pt is asked to contract the muscle powerfully & to
Regular intermittent break in resistance during maintain the contracted position while the examiner
whole range of passive movement is felt due to the tries to keep it in original position. In isometric testing,
presence of static tremor (as if a lever is rubbing on there is no shortening of muscle.
the teeth of a cogwheel). It is best observed in wrist
joint. Found in upper limb in Parkinsonism. 2.ISOTONING TESTING (i.e MUSCLE TONE CONSTANT)
3.Hypertonia is marked in both the upper & lower limb The pt is asked to contract the muscle & the examiner
equally i.e the flexor muscles & extensor muscles of opposes the movement at the initial part of contraction.
all the 4 limbs are affected equally. Isometric method is more sensitive & detects minor
4.Deep tendon reflexes are normally elicited & clonus degree of weakness though isotoning testing is
is absent. commonly practiced method in neurology.
5.Plantar reflex is flexor.
6.Frequently associated with bradykinesia, static
a.POWER IN UPPER LIMBS
tremor & postural instability. Reflex rigidity is the
muscle spasm in response to pain eg. Neck rigidity
Ask the pt to move the limb side to side on the bed,
in meningitis, cardboard rigidity in peritonitis.
raise the limb & raise the limb against examiner’s
3.PARATONIA (=GAGANHALTEN) resistance. Test the following joints against resistance.
Pt apparently opposes examiner’s attempts to move his 1.SHOULDER-Adduction, Flexion & extension
limb. Found in bilateral frontal lobe damage, 2.ELBOW-Flexion & extension
cerebrovascular disease.
b.POWER IN LOWER LIMBS
b.HYPOTONIA
Ask the pt to move the limb side to side on the bed,
Muscles feel soft & flabby & there is increased range of raise the limb & raise the limb against examiner’s
passive movement. resistance. Test the following joints against resistance.

56
1.HIP-Flexion,extension,adduction & abduction while bilateral proximal weakness suggest myopathy &
2.KNEE-Flexion & extension bilateral distal weakness suggest peripheral neuropathy.
TESTING THE MUSCLES OF THE UPPER LIMB
3.ANKLE-Plantar flexion & dorsiflexion
1.ABDUCTOR POLLICIS BREVIS
To test the power of the back of the thigh muscle, ask
the pt to lie in prone position. Now, give resistance as Ask the pt to abduct the thumb in a plane at right
the pt flexes his knee one after the other. angles to the palmar aspect of the index finger against
the resistance of your own thumb. The muscle can be
c.TRUNK felt & seen to contract.
Weakness of the muscles of the abdomen is shown 2.OPPONENS POLLICIS

by the pt’s inability to raise himself in bed without the
aid of his arms. Ask the pt to touch the tip of the little finger with the
point of the thumb. Oppose the movement with your
BABINSKI’S RISING UP SIGN thumb or index finger.
Ask the pt to lie on his back with legs extended & rise 3.FIRST DORSAL INTEROSSEUS
up without using his hands. In organic spastic paralysis
of the lower limb, the affected limb will rise first owing Ask the pt to abduct the index finger against your
to the rigidity, but in functional paralysis, this does not resistance.
occur.
4.INTEROSSEI & LUMBRICALS
BEEVOR’S SIGN
Test the pt’s ability to flex the metacarpophalangeal
Pt lies in supine position. Ask the pt to raise his head joints & to extend the distal interphalangeal joints. The
from the bed while the examiner observes the interossei also adduct & abduct the fingers.
movement of the umbilicus. In paralysis of the lower
part of the rectus abdominis (i.e paraplegia with loss of 5.FLEXORS OF THE FINGERS
sensation & sensory level below the umbilicus),
umbilicus moves upwards & becomes slit like (vertical Ask the pt to squeeze your fingers. Allow the pt to
slit). For better elicitation of the sign, apply resistance squeeze only your index & middle fingers-this is
over the pt’s forehead with your palm when the pt is sufficient to assess strength of grip without having your
raising his head from the bed. In otherwords, when fingers painfully crushed.
Beevor’s sign is positive, there is upper abdominal
muscle contraction & retained upper abdominal reflexes, 6.EXTENSORS OF THE WRIST
whereas there is absence of lower abdominal muscle
contraction & reflexes. The lesion is at the T10 (T9- Ask the pt to make a fist, which will result in firm
T10) segment. contraction of both flexors & extesors of the wrist. Then
you try forcibly to flex the wrist against the pt’s
>To test for the erector spinae muscles of the back, ask resistance to maintain the posture. It should be almost
the pt to lie down in prone position & try to raise his impossible to overcome the wrist extensors of a healthy
head from the bed by extending the neck & back. If the person. Slight weakness of the wrist extensors may be
back muscles are healthy, they will be seen to stand out elicited by asking the pt tograsp something firmly in his
prominently during this effort. hand. If the wrist extensors are weak, then the wrist
becomes flexed as he does so, because the wrist flexors
HOOVER’S CONTRALATERAL LEG SIGN are then stronger than wrist exensors.
It is a test to diagnose hysterical hemiplegia. In this 7.FLEXORS OF THE WRIST

test, when the pt attempts to raise the paralysed leg,
the opposite heel does not make counter pressure Ask the pt to squeeze your fingers. Allow the pt to make
backwards on the palm of the examiner’s hand placed a fist & try to overcome wrist flexion.
below the opposite heel as in the organic hemiplegia.
8.BRACHIORADIALIS
BABINSKI’S LEG FLEXION TEST
Place the arm midway between prone & supine position.
If a pt of organic hemiplegia is asked to sit up from Then ask the pt to bend uo the forearm whike you
supine position against examiner’s resitance, then the oppose the movement by grsdpong the hand. The
paralysed leg flexes involuntarily while in hysteria the muscle, if healthy, will stand iut promoinently at its
normal leg is flexed first. upper part.
>Power of the muscle-Unilateral weakness of the upper

limb extensors & lower limb flexors (PYRAMIDAL
WEAKNESS) suggest a lesion of the pyramidal tract

57
9.BICEPS=BICEPS BRACHII
2.DIAPHRAGM
Ask the pt to bend up the forearm against resistance
with the forearm in full supination. The muscle will stand 3.SPINAL EXTENSORS
out clearly.
TESTING THE MUSCLES OF THE LOWER LIMB
10.TRICEPS=TRICEPS BRACHII
1.INTRINSIC MUSCLES OF THE FOOT
Ask the pt to straighten out his flexed forearm against
your resistance. 2.DORSIFLEXION & PLANTAR FLEXION OF FEET &
TOES
11.SUPRASPINATUS 3.EXTENSORS OF THE KNEE
Ask the pt to lift the arm straight out at right angles to
the side. The first 30 degree of this movement is carried 4.FLEXORS OF THE KNEE
out by the supraspinatus. The remaining 60 degrees is
produced by the deltoid. Raise pt’s lower limb from the bed, supporting the thigh
with your left hand & holding the ankle with your right
12.DELTOID hand. Then ask the pt to bend the knee against your
resistance. You should not be able to overcome this
The anterior & posterior fibres of the deltoid help to muscle.
draw the abducted arm forwards & backwards
respectively. The middle fibres abduct the shoulder as 5.EXTENSORS OF THE HIP
mentioned above under supraspinatus.
With the pt’s knee extended, lift his or her foot off the
13.INFRASPINATUS bed. Then ask the pt to push it down against your
resistance. This is normally a very strong movement &
Ask the pt to tuck the elbow into the side with the should be impossible to overcome. As for the other leg
forearm flexed to a right angle. Then ask the pt to extensors, a better functional test is to obsrve the pt
rotate the limb outwards against your resistance, the standing from a low chair & hopping.
elboe being held against the side throughout. The
muscles can be seen & felt to contract. 6.FLEXORS OF THE HIP
14.PECTORALS With the pt’s lower limb extened on the bed, ask him or
her to raise the lower limb off the bed against
Ask the pt to stretch the arms out in front & then to resistance. Alternatively, the related movement of
clasp the hands together while you andeavour to hold flexion of the thigh, with the already flexed to a right
them apart. angle , can be tested.
15.SERRATUS ANTERIOR 7.ADDUCTORS OF THE THIGH
When this muscle is paralysed, the scapula is winged Abduct the pt’s lower limb & then ask the pt to bring it
with the vertebral border projecting posteriorly. The pt back to the midline against resistance.
is unable to elevate the arm above the right angle, the
deformity becoming more apparent as they try to do so. 8.ABDUCTORS OF THE THIGH
Pushing forwards with the hands against the resistance,
such as a wall, also brings out the deformity. Place the pt’s lower limb together & ask him or her to
separate them against resistance.
16.LATISSIMUS DORSI
9.ROTATORS OF THE THIGH
Ask the pt to clasp hands behind their back while you,
standing behind the pt, offer passive resistance to the With the pt’s lower limb extened on the bed, ask him or
downward & backward movement. Alternatively, the two her to roll it outwards or inwards against resistance.
posterior axillary folds can be felt as the pt coughs.
17.TRAPEZIUS
The upper part of the trapezius is tested by asking the

pt to shrug their shoulders while you try to press them
dodn from behind. The muscle’s lower part can be
tested by asking the pt to approximate the shoulder
blades.
TESTING THE MUSCLES OF THE TRUNK
1.BEEVOR’S SIGN & ABDOMINAL WEAKNESS

58
MYOTOMES 1.PLANTAR REFLEX (L5 & S1) [PRIMARILY L5]
(=BABINSKI’S REFLEX)
UPPER LIMB
-Present (Elicited)/ Not Elicited or grossly depressed
Shoulder abduction C5
Elbow flexion C5 &C6 a.CLASSICAL PLANTAR REFLEX
Elbow extension C7 & C8
Finger flexion C8 >Pt lies supine with extended legs. Ask him to relax the
Small muscles of hand T1 muscles of lower limb. Now the lower limb is partially
flexed & externally rotated. Place your lt palm over the
LOWER LIMB ankle joint with fingers not touching the Achilles tendon
Hip flexion L2 & L3 & slight pressure is applied to fix the ankle joint. Now
with the rt hand lateral border of the foot is scratched
Hip extension L5 & S1
gently with a key or pointed end of a knee hammer
Knee flexion L5 & S1 starting from the heel & then going along the lateral
Knee extension L3 & L4 border of sole towards the little toe & then turn medially
Ankle inversion L4 across the metatarsus upto the head of the second
metatarsus in a hocky stick fashion. NEVER TOUCH THE
Ankle eversion L5 & S1
BALL OF THE GREAT TOE & FLEXOR CREASES OF THE
Plantar flexion S1 & S2 TOES. Stop stimulating the sole as soon as the first
Dorsiflexion of foot & toes L4 & L5 movements of the great toe occurs. Now do the test on
the other side. This is the PLANTAR B METHOD.
>In a PLANTAR A METHOD, stimulus is not taken medi-
MUSCLE POWER GRADING ally across the metatarsus i.e only the lateral border of
the sole of the foot is stimulated.
It is obtained only when the pt is conscious since it >First stimulation taking 1-2 second & slow stimulation
requires pt’s co-operation. taking 5-6 second can be applied. Planter B method with
the slow stimulation is the best method. The duration of
GRADE CHARACTERISTICS the stimulation is more important than intensity.
0 No visible muscle contraction i.e.
complete paralysis DIFFERENT PLANTAR RESPONSES
1 Visible or palpable flicker of contraction
but no movement of joint or limb 1.FLEXOR PLANTAR RESPONSE
2 Movements possible only after elimination
of gravity i.e side to side movement of In healthy adults, even a slight stumulus produces
limb contraction of the tensor fascia lata, often accompanied
3 Movement sufficient to overcome the by a slighter contraction of the adductors of the thigh &
gravity but not against additional of the sartorius. With a slightly stronger stimulus,
(examiner’s) resistance flexion of the four outer toes appears which increases
4 Movement sufficient to overcome the with the strength of the stimulus until all the toes are
gravity & also some additional flexed on the metatarsus & drawn together with the
(examiner’s) resistance but weaker ankle being dorsiflexed & flexion of the knee & hip. With
than normal still stronger stimulus, withdrwal of the limb occurs. The
5 Normal power i.e. movement sufficient to normal plantar response is flexor type. The plantar
overcome gravity & powerful resistance reflex is never completely absent in healthy subject.
2.MINIMAL PLANTAR RESPONSE

ALTERNATIVE METHOD FOR MUSCLE POWER GRADING
On eliciting the plantar reflex, no movement of the toes
Grossly, ask the pt to lift his leg. If he can do so very is seen. The presense of positive plantar response is
very slowly with great difficulty, then the power is grade assessed by feeling for the contraction of adductors of
3. If he can lift immediately without any difficulty, then the thigh, sartorius & tensor fascia lata.
the power it is grade 4.
2.EXTENSOR PLANTAR RESPONSE
4.REFLEXES
The responses are-Dorsiflexion (extension) of the great
To be tested in upper limb, lower limb & trunk in both toe (movement occurs at metatarsophalangeal joint)
sides. preceeds all other movement. It is then followed by
spreading out (Fanning) & extension of the other 4 toes,
A.SUPERFICIAL REFLEXES dorsiflexion of the ankle, flexion of the hip & knee &
contraction of tensor fascia lata. It is found in pt with
(=CUTANEOUS REFLEXES)
corticospinal tract lesion & is thus a PATHOGNOMONIC
First test the reflexes in the normal side & then see in
FEATURE OF UMN lesion (Plantar reflex is a local reflex
the abnormal side & compare.
arc modified by the pyramidal tract). In otherwords,
59
extensor plantar response is found in UMN lesion above disease & in some pt’s with bilateral UMN lesion at a
the S1 level of the spinal cord. An extensor plantar higher level & in presence of posterior column disease-
response is often found, during sleep deep coma & in a Multiple sclerosis, subacute combined degeneration.
child below 1 year. Extensor plantar response is often
associated with hyperreflexia, hypertonicity & clonus. 7.EXTENSOR SPASM
THE FIRST MOVEMENT OF THE GREAT TOE IS
IMPORTANT. Extension of great toe after a brief initial It is found in corticospinal lesion when posterior column
flexion is not an extensor response.There is nothing function is normal.
called negative Babinski’s sign. Pseudo-Babinski’s sign
may be seen in plantar hyperaesthesia or chorea. 8.PSEUDO BABINSKI’S SIGN
>The Babinski’s sign can be elicited only by stroking the >False Babinski’s sign occurs in the absence of
lateral aspect of the dorsum of the foot in the presence pyramidal tract lesion. Here, there is no associated
of the minimal pyramidal tract lesion & in individuals contraction of the hamstring muscles & applying
with thick soles. pressure on the base of the great toe while eliciting the
>The Babinski’s sign can be elicited by stroking the plantar response inhibits the withdrawal extensor
medial aspect of the foot when the lesion becomes response.
dense (due to increase in the reflexogenic area).
>If no plantar reflex is elicited with the pt’s knee flexed PEUDO BABINSKI’S SIGN IS FOUND IN
& thigh externally rotated, it can be elicited by
extending the pt’s knee, or even applying pressure on 1.A voluntary withdrawal in overtly sensitive individuals
the knee (the thigh being in the neutral position). on attempting to stroke the sole of the foot.
2.As a response in plantar hyperaesthesia
>With repeated stimulation of the sole of the foot, the
3.Application of a strong or painful stimulus to the sole
plantar reflex may become fatigued & the extensor
of the foot.
plantar reflex may not be elicitable.
4.In athetosis or chorea, where a big toe may extend as
a response to dystonic posturing.
3.EQUIVOCAL RESPONSE
5.If the short flexors of the toes are paralysed (due to
LMN lesion), then there may be an inversion of the
This is an incomplete response where the full
plantar reflex.
components of the extensor plantar response is not
manifested e.g BABINSKI’S SIGN IN ABSENCE OF PYRAMIDAL TRACT
1.Only fanning out & extension of 4 toes is seen without LESION
any movement of the great toe. Or
2.The hemiplegic side does not show any response & the 1.Infancy (Upto 1 year of age)
healthy side shows flexor response (sometimes seen 2.Deep sleep
in early cases of CVA i.e during shock stage) Or 3.Deepp anesthesia
3.Asymmetry of flexor response in both sides. Today’s 4.Narcotic overdose
equivocal response may be tomorrow’s extensor 5.Alcohol intoxication
response. Or 6.Following electroconvulsive therapy (ECT)
4.There may be flexion of the knee & hip with no 7.Coma secondary to metabolic disturbance
movement of the toes. Or 8.Post-traumatic state
5.Only extension of great toe or extension of great toe 9.In CHEYNE-STOKES RESPIRATION, the extensor
with flexion of the smaal toes. Or response may appear during the period of apnea,
6.There is rapid but brief extension of toes at first, whereas in the phase of active respiration, the normal
which is followed by flexion or predominant flexion reflex is seen.
followed by extension. Extension#Flexion#Extension.
PLANTAR EQUIVALENCE
4.NO RESPONSE
The undermentioned signs show a positive Babinski
After scratching the sole of the foot, there is no
response when the reflexogenic area spreads up in the
movement of the any of the toes.
lower limb & are useful in eliciting Babinski response
when the pts are unco-operative or in pts whose soles
5.WITHDRAWAL RESPONSE
are extremely sensitive.
This response is often seen in normal persons with
A.OPPENHEIM SIGN
hyperaesthetic or sensitive sole. It is seen that initial
normal flexor response is quickly followed by mass
-Present/ Absent
extension of toes with withdrawal of the entire leg.
Stand on the rt side of the pt. Now apply heavy
6.FLEXOR SPASMS
pressure by placing the lt thumb & lt index finger on
either side of the shin of the tibia (below the tibial
It consists of an exaggerated extensor plantar response,
tuberosity) from above downwards. Greater pressure is
the whole limb being suddenly drawn up into flexion &
applied on the medial side. The extensor response
the great toe is extended. It is common in spinal cord
usually occurs towards the end of the stimulation.
60
>IN GENERAL, PLANTAR STIMULATION IS MORE EFFEC-
B.GORDON’S SQUEEZE (OR SIGN) TIVE THAN NONPLANTAR STIMULATION.
1. The afferent nerve of plantar reflex is tibial nerve. The
-Present/ Absent efferent nerve is tibial nerve for flexor response &
peroneal nerve for extensor response.
Squeezing the calf muscle with the rt thumb & rt index 2. When not elicited, plantar response can be reinforced
finger causes extension of the great toe with some by rotating the pt’s head to opposite side or applying
dorsiflexion of the foot. warmth to the cold skin of the sole.
C.SCHAFFER’S SQUEEZE (OR SIGN) ROSSOLIMO’S SIGN
-Present/ Absent • METHOD
Squeezing the Achilles tendon with the rt thumb & rt Either tap the ball of the foot by percussing the
index finger produces extensor plantar response. plantar surface of the ball of the great toe with
hammer or flick the distal phalanges of the toes into
D.CHADDOCK’S STROKE (OR SIGN) extension & then allow them to fall back into their
normal position.
-Present/ Absent
• RESPONSE
Scratching the skin of the lateral side of the dorsum of
the foot from below the lateral malleolus towards little Pyramidal tract lesion manifests by plantar flexion of
toe by the pointed end of the knee hammer produces all the 5 toes. It is the only sign with UMN lesion
extensor plantar response. which manifests by plantiflexion of great toe. It is the
homologue of Hoffman’s sign of upper limb.
>Chaddock’s stroke is usually done in cases in which
extensor plantar reflex can not be elicited by classical 2.SUPERFICIAL ABDOMINAL REFLEX
method (i.e plantar B method) which usually happens in (T7-T12 :-T7 to T9-Above the umbilicus &
persons thick soles (village persons not using slipper). T10 to T12-Below the umbilicus)
E.GONDA PRESSDOWN (OR SIGN) 1.UPPER
-Present/ Absent -Absent/ Present-Bilaterally/ Unilaterally-Lt/ Rt
2.MIDDLE
Plantar flexion of the little toe produces extensor plantar
response.
-Absent/ Present-Bilaterally/ Unilaterally-Lt/ Rt
F.BING SIGN 3.LOWER
-Present/ Absent -Absent/ Present-Bilaterally/ Unilaterally-Lt/ Rt
Pricking the dorsum of the foot by a pin produces Pt lies supine & relaxed with abdomen exposed. Stroke
extensor response. is given swiftly but lightly & bilaterally from OUTSIDE TO
G.MONIZ SIGN THE MIDLINE by the pointed end of knee hammer (or a
key) at 3 places-1.Below & parallel to the costal margin,
-Present/ Absent 2.At the level of umbilicus & 3.Above & parallel to the
inguinal ligament. Observe for the contraction of the
Extensor response is seen after forceful passive plantar muscles & deviation of the umbilicus towards the
flexion of the ankle. stimulus (occurs in normal person). The stroking agent
is held at an acute angle with the abdominal skin & it
H.BRISSAUD’S REFLEX should not cause any abrasion on the skin. It is often
impossible to elicit this reflex in anxious patients, eldrly
-Present/ Absent obese & multiparous women.
Contraction of tensor fascia lata as a part of extensor >IN HEMIPLEGIA, THE ABDOMINAL REFLEX IS LOST IN
response. This reflex is helpful in pts with amputated or
PARALYSED SIDE ONLY. In UMN lesion, superficial
absent great toe.
abdominal reflex is absent. This reflex is most useful
when there is preservation of the upper (spinal cord
>Oppenheim sign, gordon’s squeeze, schaffer’s squeeze, level T9) but not lower (T12) abdominal reflexes,
chaddock’s stroke, gonda pressdown plantar indicating a spinal lesion between T9 and T12, or when
equivalence methods are commonly practiced in clinical the response is asymmetric.
medicine. These methods are useful in non-cooperative
pts or when the soles are extremely sensitive or the
soles are wounded or injured.

61
COMPARE WITH THE OTHER SIDE. The knee hammer
3.CREMASTERIC REFLEX (L1 & L2)
should be held with 2 finger i.e rt thumb & rt index
finger. Use the hammer by swinging movement at the
- Present (Elicited)/ Absent (Not Elicited ) wrist joint (i.e the hammer should have a free fall).
Sudden & single blow is applied over the tendon. All the
>Pt is in supine position. The thigh is abducted & deep tendon reflexes of both the sides are tested by
externally rotated. Lightly scratch the medial aspect of standing on the rt side.
the upper part the thigh from ABOVE DOWNWARDS >Deep tendon reflexes are also known as jerks. That
(NOT BELOW UPWARDS) with the pointed end of the means Biceps Reflex=Biceps Jerk.
knee hammer. Observe for upward movement of the
ipsilateral testicles (due to reflex contraction of DIFFERENTIATION BETWEEN EXAGGERATED &
cremasteric muscles). Alternatively, this reflex can be BRISK RESPONSE
easily elicited by pressing over the sartorius in the lower
part of the Hunter’s canal. Often it is very difficult to
Roughly exaggerated reflex means, the amplitude of the
elicit this reflex in the elderly. This reflex is lost in UMN
limb movement is more & brisk reflex means the reflex
lesion i.e damage to L1 & L2 spinal segments, hydrocele
is very prompt in its response. We may conclude that
& hernia. Cremasteric muscle contraction causes hyperreflexia is only of pathological significance when it
elevation & retraction of testis. is asymmetrical (comparing with the other side) or if
associated with other signs of UMN lesion (spasticity,
>Afferent-Ilioinguinal nerve (a branch of Femoral Babinski’s sign clonus etc.)
nerve), Efferent-Genital branch of Genitofemoral
nerve >JERKS OF BOTH SIDES SHOULD BE COMPARED
BEFORE DERIVING A CONCLUSION.
4.ANAL REFLEX (S2,S3 & S4) GRADING OF TENDON REFLEXES
-Present/ Absent RESPONSE GRADE

ABSENT 0
Contraction of the anal sphincter when the perianal skin PRESENT
is scratched. It is particularly important to test for these (AS A NORMAL 1
cutaneous reflexes in any patient with suspected injury ANKLE JERK)
to the spinal cord or lumbosacral roots. BRISK
(AS A NORMAL 2
5.SCAPULAR REFLEX (C5 & T1) KNEE JERK)
VERY BRISK 3
-Present/ Absent PRESENCE OF 4
CLONUS
Stroking the skin in the interscapular region causes
contraction of the scapular muscles. INTERPRETATION OF TENDON REFLEXES
6.BULBOCAVERNOSUS REFLEX (S3 & S4) 1.Present-In health

2.Lost or diminished-LMN lesion, UMN lesion in shock
-Present/ Absent stage
3.Exaggerated-Anxiety neurosis, nervousness, hysteria,
Pinching the dorsum of the glans penis causes thyrotoxicosis, tetany & tetanus
contraction of the bulbocavernosus. 4.Brisk-UMN lesion
5.Pendular-Cerebellar lesion & chorea
7.CORNEAL REFLEX (=LID REFLEX)
UPPER LIMB DTRs
Already mentioned.
! IF SUPERFICIAL REFLEXES ARE NOT ELICITED, 1.BICEPS JERK (C5 & C6)
REINFORCEMENT TO ELICIT THESE REFLEXES CAN BE
ACHIEVED BY TALKING WITH THE PATIENT TO DIVERT
- Present (Elicited)/ Lost (Not Elicited)/ Diminished OR
HIS ATTENTION.
Grossly depressed/ Exaggerated/ Brisk
B.DEEP TENDON REFLEXES (DTR) >Uncover the entire upper limb. The elbow is semiflexed
(=MUSCLE STRETCH REFLEXES) at rt angle & the forearm is placed in a semipronated
position. The limb may rest upon your lt hand or on pt’s
PRE-REQUISITES abdomen. Place your lt thumb or index finger firmly on
the biceps tendon & tap suddenly over your finger by
Stand on the rt side of the pt (even for the elicitation of the pointed end of the knee hammer (so that the blow is
jerk on the lt side). Ask the pt to relax & lie down aimed directly through your thumb at the bicep tendon).
(supine position). EXPOSE THE MUSCLE FULLY. Tap the Observe for flexion at the elbow & watch for & feel the
tendon & not the muscle belly. Observe both contraction contraction of the biceps muscle.
of the muscle & the movement of the limb. ALWAYS
62
>Test the lt side Bicep’s jerk by standing on the rt side. -Absent (Not Elicited)-Bilaterally/ Unilaterally-Rt/ Lt
For this, pt lies in supine. Keep the lt upper arm on the
bed & flex the lt forearm to 90 degree. Rest the flexed lt Place the tips of the examiner’s middle & index fingers
forearm on the side of the abdomen on the lt side. Place across the palmar surface of the proximal phalanges of
your lt thumb or index finger firmly on the biceps the pt’s relaxed fingers. Then tap the examiner’s finger
tendon & tap suddenly over your finger by the pointed lightly with a knee hammer. The normal response is
end of the knee hammer. Observe for flexion at the slight flexion of the pt’s fingers. This becomes
elbow & watch for & feel the contraction of the biceps exaggerated if there is hyperreflexia. Hyperreflexia
muscle. means exaggerated response.
>Lesion at C5-C6 abolishes Biceps jerk.
6.HOFFMAN’S REFLEX (C7,C8 & T1)
2.TRICEPS JERK (C6 & C7 ) -Present (Elicited)-Bilaterally/Unilaterally-Rt/ Lt

-Absent (Not Elicited)-Bilaterally/Unilaterally-Rt/ Lt
-Present (Elicited)/ Lost (Not Elicited)/ Diminished OR
Grossly depressed/ Exaggerated/ Brisk Pt’s hand is pronated & the examiner grasps the middle
phalanx of the pt’s middle finger with his index finger &
Uncover the entire upper limb. Flex the elbow to right thumb of lt hand. Place the examiner’s rt index finger
angle with palm towards the body & pull it slightly under the distal interphalangeal joint of the pt’s middle
across the chest. Support the hand at the wrist by your finger. Then briskly flick down the pt’s middle finger tip
lt hand so that the upper limb does not fall on the bed. with the examiner’s rt thumbtip & allow the pt’s distal
Suddenly tap the triceps tendon just above the phalanx to spring back to the normal position while
olecranon. Watch for the contraction of the triceps & observing pt’s thumb for any movement. A positive
extension at the elbow. Care must be taken to strike the response consists of brisk flexion & adduction of pt’s
triceps tendon & not the muscle belly itself. All muscles thumb (flexion of other fingertips) which indicates UMN
show a certain amount of irritability to direct mechanical lesion in the upper limb. This reflex may not be present
stimuli, but this is a direct response, not a stretch in all pts with pyramidal tract lesion & it may be present
reflex. in a nervous individual without any organic lesion. If the
reflex is present on one side (unilateral only), it may
3.SUPINATOR=BRACHIORADIALIS JERK (C5 & have some value as a sign of pyramidal tract lesion.
C6 ) >You can also demonstrate Hoffman’s Reflex by holding
the distal part of the middle phalanx of the pt’s middle
- Present (Elicited)/ Lost (Not Elicited)/ Diminished OR finger with your index & middle finger in a cigarette
Grossly depressed/ Exaggerated/ Brisk holding fashion. Then gently flick down terminal phalanx
of the pt’s middle finger with your rt thumb & look for
Elbow is slightly flexed & forearm is semipronated. the flexion & adduction of the pt’s thumb.
Forearm rests on the abdomen or in the lap with the
palm down. Sharply tap on the styloid process of the 7.WARTENBERG’S SIGN
radius with the broad end of the knee hammer. Observe
flexion at the elbow & supination of forearm. -Present (Elicited)-Bilaterally/Unilaterally-Rt/ Lt
-Absent (Not Elicited)-Bilaterally/Unilaterally-Rt/ Lt
4.INVERSE SUPINATOR JERK (C5& C6)
(=INVERSION OF SUPINATOR JERK) The pt supinates his hand, slightly flexing the fingers,
with the thumb in abduction. The examiner pronates his
-Present (Elicited)-Bilaterally/Unilaterally-Rt/ Lt hand & hooks his flexed fingers with that of the pt’s
-Absent (Not Elicited)-Bilaterally/Unilaterally-Rt/ Lt fingers. Both then flex their fingers & pull against each
other as forcibly as possible. Normally, the thumb
When there is a lesion in the spinal cord at C5-C6 extends thouigh the terminal phalanx may flex slightly.
segment, there is hyperexcitability of anterior horn cells In the presence of UMN lesion (Hypertonia), the thumb
below this level. So,during elicitation of supinator jerk, adducts & flexes strongly. Wartenberg’s sign indicates
there is no flexion at the elbow joint but only brief pyramidal tract lesion & may be taken as an equivalent
flexion of fingers (as C7-C8 take upperhand) occur. of Babinski sign in case of amputation of both lower
Similarly,in inversion of biceps jerk, (lesion at C5-C6 limbs.
segment), there is no contraction of the biceps during
the elicitation of biceps jerk, but one can see the LOWER LIMB DTRs
contraction of the triceps(as C6-C7 take upperhand).
Inversion of a jerk localizes the level of the level of the
1.KNEE JERK (L2,L3 & L4)
lesion in the spinal cord. Usually inversion of the
(=PATELLAR REFLEX=QUADRICEPS REFLEX)
supinator & biceps jerks are seen together.
-Present (Elicited)/ Lost (Not Elicited)/ Diminished OR
5.FINGER JERK (C7,C8 & T1)
(=FLEXOR FINGER JERK)
METHODS TO DEMONSTRATE KNEE JERK
-Present (Elicited)-Bilaterally/ Unilaterally-Rt/ Lt

63
A.CONVENTIONAL METHOD stretch the Achilles tendon & with the rt hand strike the
tendon on its posterior surface with the wider side of the
>Pt lies in supine position. Now flex pt’s both the knee knee hammer. A quick contraction of calf muscle
joint by placing your lt hand & forearm in the popliteal resulting in plantar flexion at the ankle occurs.
fossa of both the knee joint to make an obtuse angle
(i.e more than 90 degree). Uncover both the thighs. The B.SPECIAL MTHOD
patellar tendon is struck sharply midway between its
origin & insertion with the pointed end of the knee Pt is in kneel down position on a chair with both feet
hammer. Observe for the contraction of the quadriceps hanging out of the chair. A sharp tap is applied on
& brief extension of knee. Observe for the symmetry of Achilles tendon (do not passively dorsiflex the foot). Calf
the reflex by comparing the amplitude of the movement muscles contract & plantiflexion of the foot occurs. It is
on one side with the other side. Normal knee jerk is done specially in myxedema cases to observe the
brisk in response. delayed relaxation time.
>In those pts in whom the reflexes are difficult to elicit
or appear to be absent, apply the technique of >Lesion at S1 abolishes Ankle jerk.
reinforcement. For reinforcement to elicit deep tendon
reflexes of lower limb, Jendrassik’s maneuver is used. >IN THE INITIAL PERIOD OF HEMIPLEGIA AND
PARAPLEGIA (UMN LESION), THERE IS AN ACUTE
JENDRASSIK’S MANEUVER (REINFORCEMENT) NEURONAL SHOCK STAGE DURING WHICH
PLANTAR AND OTHER REFLEXES ARE NOT
>Ask the pt to hook the fingers of the two hands ELICITED AND THERE IS HYPOTONIA INSTEAD OF
together & then to pull them against one another as SPASTICITY.
hard as possible immediately before striking the tendon
(Patellar & Achiles) & to relax immediately thereafter. C.CLONUS
ALWAYS PERFORM JENDRASSIK’S MANEUVER BEFORE
DECLA-RING A TENDON REFLEX ABSENT. >Clonus is the rhythmical contraction of a muscle in
response to sudden, passive & sustained stretching of
>When reinforcing the upper limb reflexes, ask the pt to
the muscle. Clonus is always associated with brisk
clench the teeth or squeeze the knees (push the knees tendon reflex, spasticity & Babinski’s sign. It is a very
hard together) immediately before striking the tendon & reliable sign of pyramidal tract lesion.
to relax immediately thereafter.
>It is very important to remember that the phenomenon >WHEN THERE IS MORE THAN 6 OSCILLATIONS ARE
of reinforcement lasts for less than a second. So the pt SEEN,IT IS CALLED SUSTAINED CLONUS(=TRUE
is asked to do the maneuver almost synchronously with CLONUS) & WHEN LESS THAN 6 OSCILLATIONS ARE
the tapping of the tendon. SEEN,IT IS CALLED UNSUSTAINED CLONUS (=PSEUDO
>Reinforcement (to make some strong voluntary CLONUS).
muscular effort) acts by increasing the excitability of 1.PATELLAR CLONUS (=KNEE CLONUS)
anterior horn cells & increasing the recruitment of
gamma fibres i.e by increasing the sensitivity of the -Sustained/ Unsustained
muscle spindle primary sensory endings to stretch
(increased gamma fusimotor drive). Pt lies supine & relaxed with knee extended. Patella is
then pulled upwards with a fold of skin behind the palm
B.SPECIAL MTHOD with the examiner’s thumb & index finger of lt hand.
Now sharply push the patella towards the foot with the
Pt sits on a chair (or bed) with legs hanging free side by thumb & index finger (so as to stretch the tendon).
side. After tapping the patellar tendon, look for the Following the initial jerk, exert sustained pressure with
pendulous movement of the legs. This pendular the thumb & index finger in a downward direction on the
movement is classically seen in cerebellar lesion. patella. If the patellar clonus is present, a series of
quadriceps contractions & relaxations producing
>Lesion at L2-L4 abolishes Knee jerk. oscillations of the patella is seen. Patallar clonus is
present in case of UMN lesion over L2,L3 & L4 spinal
2.ANKLE JERK (S1 & S2) [PRIMARILY S1] segments.
(=TENDOACHILLES REFLEX)
2.ANKLE CLONUS
-Present (Elicited)/ Lost (Not Elicited)/ Diminished OR -Sustained/ Unsustained

Pt lies in supine position. Support the flexed knee(120
A.CONVENTIONAL METHOD degree) with your lt palm in the popliteal fossa so that
the ankle rests gently on the bed. Using the other hand,
Lower limb flexed at the knee & foot is slightly everted suddenly & briskly dorsiflex the foot by pressing the
i.e foot is externally everted. (The foot may rest on the upper part of the sole with the right palm (Palmar
opposite limb). EXPOSE THE CALF MUSCLES FULLY. Now aspect of four fingers except thumb) & raise the foot off
slightly dorsiflex the foot with the lt hand so as to the bed so that HEEL DOES NOT TOUCH THE BED.

64
Following the initial jerk, sustain the steady pressure & Pt flexes the elbow against resistance which is suddenly
observe for to-and-fro movement of the foot & a series released. Observe for the oscillation of forearm.
of contractions and relaxations of calf muscles when
ankle clonus is present. Ankle clonus is produced in UMN d.DESCRIBE A CIRCLE IN AIR WITH FINGER
lesion above the level of S1 & S2 spinal segments.
-Can/ Can’t
3.JAW CLONUS
Ask the pt to describe a circle in the air with his index
Elicit the jaw jerk & observe for series of closure & finger.
opening of the mouth. (Others-Threading a needle. Watch the pt while dressing
or undressing, picking up pins from the table, combing
3.WRIST CLONUS etc.)
Elicited by sudden passive extension of the fingers. II.IN LOWER LIMB-
>Jaw clonus & wrist clonus is not routinely practiced in a.HEEL-SHIN/ HEEL-KNEE TEST
clinical neurology.
>Never forget to examine a pt for clonus if there is -Normal/ Impaired
presence of brisk tendon reflex.
>Pt lies supine with eyes open. Ask the pt to lift one leg
>Patellar clonus or ankle clonus if present are surest
straight up in air, then bend the knee & place the heel
sign of UMN lesion. of the raised leg on the opposite leg below the tibial
tuberosity & then slide the heel down the surface of the
5.CO-ORDINATION (OF MOVEMENT) tibial shaft towards the ankle. After reaching the ankle,
ask the pt to keep his leg on the bed. Repeat several
-Intact/ Could not be tested because of spasticity or times in quick succession. Each time pt reaches the
rigidity (i.e, in case of hypertonia) ankle, ask him to keep his leg on the bed & then restart.
Now ask the pt to do the test on the other side. Observe
A.CEREBELLAR CO-ORDINATION errors in the direction & speed of movement. Before
doing the test, demonstrate it clearly to the pt.
I.IN UPPER LIMB- >To render the test more complex, ask the pt first to
raise the leg & to touch the examiner’s finger with the
a.FINGER-NOSE TEST big toe before placing the heel on knee.
-Normal/ Abnormal b.WALKING
Ask the pt to touch his nosetip with the tip of his own 1.Along a straight line-Can walk/ Deviation
index finger & then examiner’s rt index finger held in 2.TANDEM WALK (=HEEL-TOE TEST)
front of the pt’s face first with the eyes open & then
eyes closed. To make the test more discerning, move Ask the pt to walk along a line placing the heel of one
the target finger tip from one position to another, foot immediately adjacent to the toe of the one
backwards & forwards as well as side to side & ask the behind.
pt to touch the fingertip & then his nose with his eyes
open. c.DESCRIBE A CIRCLE IN AIR WITH THE TOE
>To test for the ataxia due to proprioceptive deficit i.e - Can/ Can’t
impairment of position sense in the limb (sensory
ataxia), now ask the Pt. to bring the outstretched B.SENSORY CO-ORDINATION
fingertip to touch the nosetip with eyes closed.
a.ROMBERG’S SIGN (DORSAL COLUMN)
b.DYSDIADOCHOKINESIA/
RAPID ALTERNATING MOVEMENT - Positive/ Negative
-Present/ Absent >Ask the pt to stand with his bare feet placed close to
eachother with eyes open initially. If he can do this, he
>Flex elbow to right angles & then alternately pronate & is then asked to close his eyes with his feet close
supinate as rapidly as possible. together. Romberg’s sign is said to be present or
>Place one palm upwards & then hit the upfacing palm positive when the pt begins to sway or about to fall as
with the palmar & dorsal aspects of the fingertips of soon as he closes his eyes. The cardinal feature of this
the other hand alternatively as rapidly as possible. sign is that the pt is more unsteady while standing with
his eyes closed than when the eyes are kept open. It is
c.IMPAIRED CHECK SIGN/ REBOUND SIGN important to remember that ROMBERG’S SIGN IS A
SIGN OF SENSORY ATAXIA & IS NOT A TEST FOR
-Present/ Absent CEREBELLAR FUNCTION. A pt with cerebellar ataxia
or labyrinthine lesion sways (or shows little increase in

65
instability) at the beginning of the test with open eyes. Keep the pt’s upper limb on bed with forearm fixed. Now
IN SIMPLE WORDS, IF THE PATIENT SWAYS WITH EYES the wrist is passively extended by holding the finger for
OPEN, IT IS DUE TO CEREBELLAR ATAXIA & IF THE a few seconds & then the pressure is released. Pt is then
PATIENT SWAYS AFTER THE EYES ARE CLOSED, IT IS instructed to keep the hand in extended position &
DUE TO SENSORY ATAXIA. Romberg maneuver is observe for the flapping tremor in the extended hand. It
primarily a test of proprioception. is also called ASTERIXIS OR BAT’S WING TREMOR.
>If the pt falls with eyes shut, then it indicates ASTERIXIS (=LIVER FLAP= FLAPPING TREMOR)
loss of joint position sense at the ankles.
>Romberg’s sign is positive in sensory ataxia & is It is non-rhythmic, asymmetric lapse in voluntary
negative in cerebellar ataxia. sustained position of the extremities, head & trunk. It is
best demonstrated by having the pt extend the arms &
then dorsiflex the hands. Because elicitation of asterixis
METHOD TO TEST ROMBERG’S SIGN IN UPPER LIMB depends on sustained voluntary muscle contraction, it is
not found in the comatose pt i.e it is not found in
Ask the pt to sit down & extend his both the upper limbs hepatic coma.
to his front & then close his eyes. In case of cerebellar >First look for static tremor, then for kinetic tremor,
ataxia, the upper limbs will sway up & down with eyes then for intention tremor & at last for flapping tremor.
open. In case of sensory ataxia, the upper limbs will
sway up & down with eyes closed. Tell this test only B.CHOREA
when you are asked, otherwise not.
Jerky, small-amplitude, purposeless involuntary
movements. In the limbs choreas resemble fidgety
6.INVOLUNTARY MOVEMENTS
movements & in the face choreas resemble grimaces.
1.Location Choreas suggest disease in the caudate nucleus as in
2.Quality-Fine/ Coarse Huntington’s disease or excessive activity in the
3.Rate-Fast/ Slow with Closed Eyes/ Opened Eyes striatum due to dopaminergic drugs used to treat
4.Aggravating Factors-Activity/ Fatigue/ Emotion Parkinsonism etc.
C.ATHETOSIS
A.TREMOR
-Static/ Kinetic/ Intention/ Flapping Slower writhing movements of the limbs. Often seen
combined with chorea & are then termed choreo-
Tremor is the rhythmic oscillatory movements.
athetoid movements. Site of lesion is at lentiform
a.METHOD TO DEMONSTRATE KINETIC TREMOR nucleus (Globous pallidus)
(=ACTION TREMOR)
D.HEMIBALLISMUS
>Ask the pt to extend the arms in front of him &
Unilateral ballistic movements of the limbs or sudden &
separate the fingers & observe the hands for COARSE
often violent flinging movement of a proximal limb
tremors. If tremor is not seen with extended arms,
usually an arm. Seen in vascular lesions of the
place a paper on the dorsum of the hands (or over the
subthalamic structures (Subthalamic nucleus).
dorsal aspect of the outstretched fingers) & look
tangentially to see FINE (i.e7-10/second) tremor.
E.DYSTONIA
According to Harrison, fine tremor is best elicited by
asking the pt to stretch out their fingers and feeling the Movement disorder in which a limb or the head
fingertips with the palm of the examiner. involuntarily takes up an abnormal posture. May be
>Pt is asked to protrude his tongue out of the oral cavity generalized as in various diseases of the basal ganglia
resting over the lower lip for at least 30 seconds & or may be focal or segmental, as in spasmodic torticollis
observe for tremor. when the head involuntarily turns to one side. Other
>Action tremor is characterized by fine in nature (7-10/ segmental dystonias may cause abnormal disabling
second), disappears at rest & appears in precise & postures of a limb to be taken up during certain specific
accurate movements, may be seen in tongue, lips & actions, such as in writer’s cramp or numerous other
head (other than limbs). occupational cramps.
b.METHOD TO DEMONSTRATE INTENTION TREMOR F.MYOCLONUS
The pt is asked to hold a glass of water kept on the Brief, isolated, random, non-purposeful jerks of muscle
table or perform finger nose test. Observe the groups in the limbs. Myoclonic jerks occur normally at
movement which becomes clumsy before he holds the the onset of sleep (hypnic jerks). Myoclonic jerk is a
glass of water or touches his nose. This tremor appears component of the normal startle response which may be
at the goal point of an action & is absent at rest & in the exaggerated in some rare (mostly genetic) disorders.
beginning of any movement. This tremor is coarse (4- Myoclonus may occur in the disorders of the cerebral
5/second) in nature. cortex, when groups of pyramidal cells fire
spontaneously. Such myoclonus occurs in some forms of
c.METHOD TO DEMONSTRATE FLAPPING TREMOR
66
epilepsy in which the jerks are fragments of the seizure SENSORY DERMATOMES
activity. Myoclonus can arise fron subcortical structures
or, more rarely, from the diseased segments of the Pt is considered to be standing with the palm of the
spinal cord. hands facing forwards
1.C1-No cutaneous supply; supplies meninges
G.TICS 2.C2-Occiput, angle of the mandible, over the
parotid gland & Earlobe
Repetitive semi-purposeful movements such as blinking, 3.C3-Nape (Back) of the neck
winking, grinning screwing up of the eyes. They are 4.C4-Above & below clavicle
distinguished from the other involuntary movements by 5.C5-Deltoid; outer aspect of the shoulder tip
the ability of the pt to suppress their occurrence, at 6.C6-Radial half of anterior forearm including palmar
least for a short time. Tics may become frequent at aspect of thenar eminence & palmar aspect of thumb
certain times in the childhood & then disappear. Gilles 7.C7-Middle finger (Palmar aspect)
de la Tourette syndrome consists of a tendency to 8.C8-Little finger, hypothenar eminence & ulnar aspect
multiple tics & odd vocalizations. of hand
9.T1-Ulnar aspect of forearm
H.OTHER MOVEMENTS 10. T2-Ulnar aspect of arm
11. T3-Axilla
Do not tell about involuntary movements in the exam 12. T4-Nipple
unless asked, but you must know in detail about the 13. T6-Xiphisternum
various involuntary movements so that you can answer 14. T8-Rib margin
common questions if at all asked. 15. T10-Umbilicus
16. T9-Area between T8 & T10
7.GAIT 17. T12-Pubis (Above the Inguinal ligament)
18. T11-Area between T10 & T12
-Normal/ Hemiplegic/ Could not be tested 19. L1-Over the Inguinal ligament
20. L2-Below the inguinal ligament
IV.SENSORY FUNCTION 21. L3-Lower medial side above the Knee
22. L4-Medial aspect of leg, Great toe(Dorsal, Ventral &
-Tested in upper limb, lower limb & trunk both in the rt Medial aspect)
& lt side 23. L5-Lateral aspect of leg (Runs diagonally from outer
aspect of tibia to the inner aspect of the foot),
>SENSORY FUNCTION IS TESTED ONLY WHEN THE
Dorsum of the foot (Excluding a smaal area on the
Pt IS FULLY CONSCIOUS SINCE IT REQUIRES Pt’S
lateral aspect)
FULL CO-OPERATION. OTHERWISE TELL “SEN-
24. S1-Little toe (Dorsal, Vntral & Lateral aspect),
SORY FUNCTIONS COULD NOT BE TESTED BECA-
Achilles tendon & strip of skin above it. We walk on
USE OF THE ALTERED SENSORIUM”.
S1.
>FIVE PRIMARY SENSORY MODALITIES INCLUDE-PAIN, 25. S2-Back of the thigh & Leg (Calf muscles &
LIGHT TOUCH, TEMPERATURE, VIBRATION & JOINT
hamstrings)
POSITION SENSE.
26. S3-Skin over the gluteal fold
>Begin with testing touch & position sense & pin prick
27. S4 & S5-Perineum (Perianal region)
later from abnormal area to normal area.
>A dermatome is a band of skin innervated by the
BASIC PRINCIPLES OF TESTING SENSORY
sensory root of a single spinal nerve.
FUNCTIONS
Explain the pt clearly what is going to be tested. Pt’s A.SUPERFICIAL SENSATION

cooperation & alertness are essential and try to gain
confidence by proper understanding. First test with the 1.TOUCH (LIGHT TOUCH)
eyes open & then eyes closed. Always compare the
sensory function with the opposite side for symmetry. >Touch is abolished/ Reduced/ Mislocalised/
First apply the sensory stimulus to the area of altered Misperceived-Painful/ Irritation/ Tingling sensation
sensation & delineate its border by testing from
abnormal to normal area. Test the dermatomes >Pt closes his eyes & responds verbally to each touch.
sequentially. Comparison of response on one side of the
Stimulate the skin with single very gentle touches of a
body to the other is essential. wisp of cotton (or tip of your index finger or a fine camel
hair brush) dermatomewise & avoid regular timed
SENSORY TRACTS stimuli. Compare the sensation in each limb for
symmetry i.e to know wheather the sensory loss is
1.SPINOTHALAMIC TRACTS-Transmits pain, temperature symmetric or asymmetric. Outline the borders of any
& crude touch. abnormal area of sensation by testing from the
hypoaesthetic area towards normal. Examine the spinal
1.POSTERIOR COLOUMN-Transmits positon, vibration & segments sequentially.
fine touch. >Fine touch is tested by a small piece of cotton wool
which is twisted into a fine hair while crude touch is tes-

67
ted by the tip of rt index finger (or the wider side of the
Ask the pt to close his eyes. Place the foot of a vibrating
cotton wool). You can also test fine touch by using tuning fork of 128Hz (Never use 256 Hz) sequentially
monofilaments. over the tip of big toe, lateral mlleolus or medial
>In general it is better to avoid testing touch sensation malleolus, shin of tibia, tibial tuberosity & anterior
on hairy skin because of the abundance of sensory superior iliac spine for lower limb & over knuckles,
nerve endings that surround each hair follicle. styloid process of radius, olecranon process, shoulder tip
>CRUDE TOUCH –A sensation perceived as light touch for upper limb & over ribs or costal margin, sternum,
but without accurate localizations. clavicles & vertebral spines for trunk. Ask the pt when
>FINE TOUCH –Touch i.e accurately localized & finely he ceases to feel it. If the examiner still can perceive it
at the same site as in the pt, then the pt’s perception of
discriminating.
vibration is impaired. From time to time place the non-
vibrating fork to avoid rt from guessing. Always
2.PAIN
compare with the other sides. Control sites-Place the
tuning fork over the pt’s sternum & forehead. Vibratory
a.SUPERFICIAL PAIN
thresholds at he same site in the pt & in the examiner
-Intact/ Impaired/ Lost are compared for the control purposes. Vibratory
thresholds at the same site in the pt & in the examiner
A series of pin prick of uniform intensity (avoid heavy is compared for control purposes.
pressure) is given dermatomewise. Pt is asked to tell if
he feels the same or not when two areas are stimulated. >The rule goes like this-IF THE DISTAL VIBRATION
Always test from an area of abnormality towards normal SENSATION PERSISTS, IT IS USELESS TO EXAMINE THE
PROXIMAL PARTS, BUT IN CASE OF LOSS OF DISTAL
skin. Select the presternal area for baseline sharpness
SENSATION, ALWAYS MOVE PROXIMALLY IN TURN.
before testing a limb. Ask wheather the quality of
>128 Hz tuning fork decays 15 to 20 seconds later
sensation becomes sharper or painful (hyperaesthesia)
or feels blunter (hypoaesthesia). The pt is asked to compared to 512 Hz & hence is preferred over 512 Hz
focus on the pricking or the unpleasant quality of the tuning fork.
stimulus & not just the pressure or touch sensation
elicited by the pin prick. Areas of hypoalgesia should be 2.SENSE OF PASSIVE MOVEMENT
mapped by proceeding radially from the most (DORSAL COLUMN)
hypoalgesic site.
b.DEEP PAIN
>Tested in-
-Intact/ Impaired/ Lost a.Upper limb-Terminal interphalangeal joint of thumb &
index finger
Tested by pinching the Achilles tendon. b.Lower limb-Interphalangeal joint of big toe.
It is essential that the pt should be relaxed sufficiently

3.THERMAL SENSATION
to allow the digit to be moved passively. Show the pt
the intended movemets of the joint & name them up &
down. Now, grasp the terminal phalanx on its lateral &
1.Tests for cold medial side at its interphalangeal joint (not on its dorsal
2.Tests for hot & ventral aspect) with the thumb & index finger of your
rt hand. Move the terminal phalanx up & down not
Glass or copper testubes containing hot (44 C) & cold exceeding 100 to 150, a number of times, finally leaving
(30 C) water are touched to the skin in a random it in some definite position & the pt is asked to say the
manner so as to avoid guessing by the pt (A rough direction i.e UP or DOWN in which the phalanx is moved
assessment of temperature sensation can be assessed with eye closed. TAKE CARE TO ENSURE THAT
EXAMINER’S FINGER DOESN’T RUB AGAINST THE
by touching the tuning fork or bell of the stethoscope for
PATIENT’S OTHER FINGERS. Movements of less than 10
cold & rubbing the palms for hot.)
degrees can be appreciated at all normal joints. At least
four wrong answers should be received before
B.DEEP SENSATION concluding that joint sensation is impaired or lost & then
it is performed at wrist, elbow, ankle, knee joint i.e
PRIMARY MODALITIES OF SENSATION (TOUCH, PAIN &
TEMPERATURE) MUST BE INTACT BEFORE TESTING FOR proximal joints in sequence. IT MUST BE EMPHASIZED
DEEP SENSATION. THAT NO OTHER PARTS OF THE EXAMINER’S BODY
EXCEPT THE LEFT INDEX FINGER & THE LEFT THUMB
SHOULD BE IN CONTACT WITH THE PATIENT’S BODY.
1.VIBRATION SENSE
(DORSAL COLUMN) 3.JOINT POSITION SENSE
a.Lost-Proximally/ Distally/ Lost over tibial tuberosity or
(DORSAL COLUMN)
styloid process of radius etc.
Pt closes his eyes & the joint in a limb to be tested is
put in a particular position. Then pt is asked to hold the
b.Impaired-Proximally/ Distally
other limb in a similar position.

68
Pt closes his eyes. Ask the pt to identify a coin (or
4.CORTICAL SENSATION other familiar objects) placed in his palm by feel alone.
Recognition of size, shape, weight & form of a common
PREREQUISITE object & identification of it by touch alone is known as
stereognosis. Pt’s failure to identify the common objects
PRIMARY MODALITIES OF SENSATION SHOULD BE by this method is known as astereognosis.
INTACT PRIOR TO TESTING FOR CORTICAL SENSATION.
If primary modalities of sensation are absent, we can d.GRAPHAESTHESIA
not test cortical sensations. Or in otherwords, testing
cortical sensations are meaningful only when primary -Intact/ Impaired/ Lost
sensations are intact because cortical sensations
mediated by the parietal lobes represent an integration Pt closes his eyes. Write a letter or a digit with a blunt
of the primary sensory modalities. Five primary sensory object (or with your index finger) on palm (back, thigh,
modalities include- Light touch, pain, temperature, anterior forearm) & ask the pt to identify the letter or
vibration & joint position sense. the digit. The accuracy & speed with which the letter or
the digits are identified are compared for two palms.
>Double simultaneous stimulation is especially useful as Clear figures like 8, 4 & 5 should be used. More difficult
a screening test for cortical function-With the pt’s eye figures like 6, 9 & 3 are used as finer tests.
closed, the examiner lightly touches one or both hands
& asks the pt to identify the stimuli. With parietal lobe e.SENSORY INATTENTION/TACTILE INATTENTION
lesion, the pt may be unable to identify the stimulus on (=BILATERAL SIMULTANEOUS STIMULATION)
the contralateral side when both hands are touched.
>Always compare with the other side. -Intact/ Impaired/ Lost
a.TACTILE LOCALIZATION Pt closes his eyes & outstretches his arms. Touch
(=TOUCH LOCALIZATION) identical points of both hands simultaneously & the pt is
asked whether he is touched on rt or lt or both sides. In
-Intact/ Impaired/ Lost unilateral parietal lobe lesion, the sensation on the
opposite side is not perceived by the pt (or identical
>Ask the pt to close his eyes & to localize the tactile points on two sides of the body are pricked with a pin
separately with eye remaining closed. If the pt can
stimuli applied by wisp of a cotton or tip of examiner’s
identify the pin prick in both situations, the previous
right index finger to various parts of the body-Hand,
points are now pricked simultaneously.)
fingers, face etc. with his fingertip.
>Ask the pt to discriminate right from left & which finger
is touched. Ability to localize the touched point is more C.DEFINITE LINE OF SENSORY LOSS
precise at periphery than proximally. ON TRUNK
b.TACTILE DISCRIMINATION *Sensory functions are normal.
(=TWO-POINT DISCRIMINATION)
D.VISCERAL/SPHINCTERIC REFLEX
1.MICTURITION REFLEX
>Pt closes his eyes. Two points of a blunt divider
-Intact/ Lost
touched simultaneously on the pulp of fingers & toes &
the pt is asked wheather he is touched with one or two Pt is asked about bladder & urethral sensation,
points. Determine the minimum distance at which pt can retention, incontinence, urgency, hesitancy or difficulty
feel two points. in controlling or initiating micturition.
>Normally, two points separated by a distance of 3 mm 2.DEFECATION REFLEX

(3-5 mm) on the finger pulps & lips, 2-3 cm on the
palm, 1cm on the pulp of toes, 4 cm on the sole of -Intact/ Lost
the foot, 5 cm and above on the dorsum of the foot,
5 cm and above on the legs & 3-5cm on any part of Pt is asked about rectal sensation & incontinence of
trunk are recognized as two separate points. feces. The reflex action of the anal sphincter can be
>If two-point discrimination is lost in the presence of tested by introducing gloved & lubricated (Xylocaine
intact posterior coloumn sensations, then it indicates jelly) rt index finger into the anus & noting wheather
parietal lobe lesion. contraction of the sphincter occurs with the normal force
or it is weak or paralysed or wheather any spasm is
c.STEREOGNOSIS excited. The activity of the reflex may also be tested by
demonstrating anal reflex.

69
V.ANCILLARY EXAMINATION Extension of the shoulder causes pain when carried out
with the elbow extended.
Test both in rt & lt sides.
>All the aforementioned tests of meningeal irritation are
positive in inflammatory conditions of meninges like
A.SIGNS OF MENINGEAL IRRITATION MENINGITIS, MENINGISM & SUBARACHNOID HEMORRH-
AGE. This is also seen in pts with raised intracranial
1.KERNIG’S SIGN pressure in whom the herniation of the cerebellar tonsils
into the foramen magnum has begun.
-Positive-rt or lt / Negative-rt or lt
B.TESTS FOR NERVE ROOT ENTRAPMENT
Pt is in supine position. Fully flex the thigh (Hip joint) on
the abdomen & then extends the knee joint. Look to pt’s 1.STRAIGHT LEG RAISING (SLR) TEST
face for pain & feel for the spasm of hamstrings
resisting extension of knee joint in a positive case. - Positive/ Negative
>The test is positive in meningeal irritation affecting
lower part of the spinal subarachnoid space. Pt is in supine position. Stand on the rt side of the pt &
place your lt palm on the patella of extended knee joint.
Place your rt palm below the heel & raise the lower limb
straight upwards with extended knee & look to pt’s face
2.BRUDZINSKI’S SIGN for pain (Facial grimacing). When the pt feels pain,
lower the leg till the pt becomes comfortable. Now
It is a very helpful sign of meningeal irritation in keeping the knee joint extended with the right palm
children. It has following 2 components- placed below the heel, dorsiflex the foot with your lt
hand. If there is sacroilitis, pt winces with pain. The
test is positive i.e restricted movement with pain is
a.BRUDZINSKI’S LEG SIGN
present in sciatica & prolapsed intervertebral disc.
-Positive-rt or lt / Negative-rt or lt 0
>Movement upto 90 is possible in a normal person.
Pt is in supine position with extended legs. Passive >LASEGUE’S SIGN=POSITIVE SLR TEST
flexion of knee & hip of one lower limb causes similar >A positive SLR test at ≤ 400 suggests root compression
flexion of the other lower limb not touched. It indicates (due to prolapse of intervertebral disc).
extreme degree of meningeal irritation. Usually, we do
not get Brudzinski’s leg sign. This sign is present when
there is an extreme degree of meningeal irritation
VI.CEREBELLAR FUNCTION
involving the lower part of the spinal cord.
>Test in both sides-Right & left.
b.BRUDZINSKI’S NECK SIGN
1.PENDULAR KNEE JERK
Pt is in supine position with extended legs. Try to lift the -Present/ Absent
pt’s head from the bed by placing your palm on the
occiput. There will be reflex flexion of hip or knee of one The pt will sit on a chair with legs hanging free side by
or both the lower limbs in a positive case. side. Apply a sharp tap on the patellar tendon on each
side, one after another. Contraction of the quadriceps
3.NECK RIGIDITY/ NECK STIFFNESS with extension of the knee occurs. In case of cerebellar
lesion the movements become pendular in nature i.e the
-Present/ Absent first movement is followed by a series of diminishing
oscillations before finally coming to rest. According to
Pt is in supine position. Remove the pillow if pres- some, three to-and-fro movements in the leg are known
ent. Stand on the rt side of the bed & place your lt palm as pendular. If no response occurs, perform the
below the pt’s head & rt palm horizontally on the front JENDRASSIK’S MANEUVER. Pendular knee jerk is due to
of the chest over the upper part of sternum. Try to lift hypotonia.
the head from the bed & flex it several times in an 2.INTENTION TREMOR
attempt to touch the chest with the chin. Feel for the
resistance while flexing & look for the facial grimacing -Present/ Absent
due to pain. (In sitting position of the pt, ask him to The pt is asked to hold a glass of water kept on the
touch the chest with the chin with closed mouth). NECK table or perform finger nose test. Observe the
STIFFNESS IS A MORE SENSITIVE TEST THAN movement which becomes clumsy before he holds the
KERNIG’S SIGN. glass of water or touches his nose. This tremor appears
at the goal point of an action & is absent at rest & in the
4.BICKEL’S SIGN beginning of any movement. This tremor is COARSE (4-
5/SECOND) in nature.

70
3.FINGER-NOSE TEST -Present/ Absent
-Normal/ Abnormal The limb overshoots beyond the normal range after
As mentioned above. sudden release of the resistance. Ask the pt to flex his
elbow against the resistance offered by the examiner.
4.DYSDIADOCHOKINESIA As soon as you withdraw the resistance suddenly, the
pt’s hand tends to strike his face (because the
-Normal/ Abnormal antagonistic muscle like the triceps can not contract
As mentioned above. promptly. This phenomenon is due to muscular
hypotonia.
5.NYSTAGMUS
12.DYSSYNERGIA
-Present/ Absent
-Present/ Absent
Horizontal jerky nystagmus is present & the direction of
Often the movements may be broken down into their
nystagmus is towards the side of lesion
component parts (Decomposition of movements)
producing small, jerky & clumsy movements (like the
modern break dance). The pt feels difficulty in
6.REELING GAIT performing the complex movements.
-Present/ Absent VII.SKULL & SPINE

1.Ask the pt to walk along a straight line. The pt walks
1.EXAMINATION OF SKULL
on a broad base, the feet being placed widely apart &
irregularly. The pt sways & often falls towards the side -Normal/ Any deformity
of lesion during walking. At times, the head is tilted
towards the side of the lesion. The entire scalp should be firmly palpated for bony
2.Then test for tandem gait as mentioned above. It is defects or abnormal protuberances. Painful points may
very difficult for a pt with cerebellar lesion to walk be present with vascular or muscle tension headache. A
steadily by tandem gait. This gait is a sensitive test CRACKED POT sound may be heard on percussion in
for early ataxia. fracture of skull & in internal hydrocephalus. The
presence of a bruit on auscultation is suggestive of
7.HYPOTONIA intracranial aneurysm or angioma.
-Present/ Absent
2.EXAMINATION OF SPINE
Elicit the tone of the muscle & it will be flaccid both at
a.Kyphosis / Scoliosis / Kyphoscoliosis/ Spina bifida/
rest & during passive movement of the parts.
Gibbus (Localised bulging) / Angulation / Scar (Old
8.TITUBATION trauma)
-Present/ Absent b.Localised tenderness
Nodding of the head. Sometimes there is head tilt. Tenderness of spine is elicited by pressing on the thumb
moving from above downwards or stroking with the
9.SCANNING SPEECH
pointed end of the knee hammer moving from above
downwards.
-Present/ Absent
c.Swelling in paraspinal area
There is dysarthria of scanning type. The speech is
usually slow, slurred & irregular. Often the pt scans the
>One must examine spine in all neurological cases
speech i.e he speaks syllable by syllable. Ask him to say
artillery: he will pronounce it as ar-til-ler-y. specially when dealing with paraplegia.
10.DYSMETRIA SOME IMPORTANT LANDMARKS
-Present/ Absent 1.Spine of scapula corresponds to T3

2.Inferior angle of scapula corresponds to T 7 (Inferior
It means inability to arrest the movements at desired angle of scapula usually lies at the level of the 7th rib
point & is elicited by finger-nose test as mentioned or 7th ICS posteriorly).
above. In cerebellar lesion, the index finger of the pt 3.Highest point of iliac crest corresponds to upper
may fall short (i.e hypometria) or overshoot (i.e border of L4 (4th lumbar vertebra).
hypermetria or past pointing) his nose. 4.Ask the pt to bend his neck forward. The most
prominent & easily palpable spinous process in
11.REBOUND PHENOMENON cervical area is the spinous process of 7th cervical
vertebra (C7).
71
5.Median angle of the scapula lies at the level of the disc
between the 1st & 2nd thoracic vertebra & just covers GENITOURINARY SYSTEM
the 2nd rib.
6.The roots of the lung lie in the interscapular region
EXAMINATION
opposite to the spines of the 4th, 5th & 6th thoracic
vertebrae. I.INSPECTION
>These important landmarks are utilized to determine
the level of the spinal cord lesion from the 1.GENITALIA
corresponding vertebral level.
-Penile swelling/ Vulval edema/ Scrotal swelling/
DETERMINATION OF SPINAL CORD SEGMENT Contact ulcer
RELATED TO A GIVEN VERTEBRAL BODY
II.PALPATION
1.For CERVICAL vertebrae-add 1 level
2.For THORACIC vertebrae T1 to T6-add 2 levels 1.KIDNEY
3.For THORACIC vertebrae T7 to T9-add 3 levels
4.The TENTH THORACIC arch overlies lumbar L1 & L2 2.RENAL ANGLE TENDERNESS
segments
5.The ELEVENTH THORACIC ARCH overlies lumbar 3 & 4 - Present / Absent
segments
6.The TWELFTH THORACIC ARCH overlies lumbar 5 The pt sits up & holds his arms in front so that the back
segments is stretched enough for better palpation. Now the
7.The FIRST LUMBAR ARCH overlies the sacral & examiner presses his thumb on the renal angle formed
coccygeal segments by the lower border of the 12th rib & outer border of
erecter spinae. Look to pt’s face for pain (i.e facial
>IN THE LOWER THORACIC REGION, THE TIP OF A grimacing).
SPINOUS PROCESS MARKS THE LEVEL OF THE
BODY OF THE VERTEBRA BELOW. 3.FLUID THRILL
>Determination of spinal cord segments related to a
given vertebral body is required because of the 4.PARIETAL EDEMA
disproportionate growth in length of the vertebral
column as compaired to spinal cord during development 5.EXAMINATION OF GENITALIA-for scrotal
so that the spinal cord remains much smaller than the edema, hydrocele, phimosis, contact ulcer in genitalia,
vertebral canal. palpation of testis etc.
5.EXMINATION OF AN III.PERCUSSION
UNCONSCIOUS PATIENT 1.SHIFTING DULLNESS
>Determination of side of hemiplegia in an unconscious 2.UPPER BORDER OF LIVER DULLNESS

patient-
3.BAND OF COLONIC RESONANCE OVER THE
A.Away from the paralysed side-Conjugate deviation of
RENAL MASS
the eyes.
B.On the hemiplegic side- 4.PERCUSSION OF THE URINARY BLADDER
• Cheeks puffs out during respiration
Nasolabial fold is obliterated
•
• Coneal reflex diminished
IV.AUSCULTATION
• Pain stimulation is less effective
• More absolute flaccidity of limbs(drooping tests) 1.RENAL ARTERY BRUIT
• Paralysed leg extended & assumes a position of
external rotation while the healthy one tends to be 2.VENOUS HUM
semiflexed
• Pupil is large on the side of the hemorrhage
• Eyelid release test-Eyelid slides down slowly after
both the eyelids are pulled up & released
simultaneously
• Temperature of paralysed side is usually higher
>Eye deviation away from the side of the hemiparesis is
common with recent infarction in the middle cerebral
artery territory.Eyes are deviated to the side of the
hemiplegia suggests pontine lesion

72
4.Number
LYMPHORETICULAR SYSTEM 5.Size
EXAMINATION 6.Shape
7.Extent
8.Surface
CLASSIFICATION OF NECK NODES ACCORDING TO
9.Margin-Discrete/Confluent
LEVELS
10. Consistency (Palmar aspect of three fingers)-Soft/
Elastic & rubbery/ Firm, discrete & shotty/ Stony
LYMPH NODE LEVEL LYMPH NODE SITE hard/ Variable/ Hard/ Discrete
LEVEL I IA- Submental Nodes 11. Mobility-Movable/ Fixed
IB- Submandibular Nodes 12. Fixity to surrounding skin-Yes/ No
13. Matting-Present/ Absent
LEVEL-II Upper Jugular Nodes
14. Examination of draining LNs
LEVEL-III Middle Jugular Nodes
15. Examination of LNs in other parts of body
LEVEL-IV Lower Jugular Nodes
LEVEL-V Accessory Nerve Nodes
Supraclavicular Nodes METHOD OF LYMPH NODE PALPATION
Suboccipital Nodes
Parotid Nodes 1.Nodes are palpated symmetrically on both sides of
LEVEL-VI Prelaryngeal Nodes the body from above downwards.
Pretracheal Nodes 2.Enlarged lymph nodes should be carefully palpated
Paratracheal Nodes with the PALMAR ASPECTS OF THE MIDDLE 3
LEVEL-VII Nodes of Upper Mediastinum FINGERS OF BOTH HAND by rolling the pulp of the
fingers against the swellings while maintaining slight
pressure to know the actual consistency of the
swelling.
I.INSPECTION 3.NECK LYMPH NODES
These nodes are always palpated from behind in sitting
1.LYMPH NODE ENLARGEMENT position of the pt with the pt’s head bending forward (to
relax the muscles in the anterior part of the neck. If one
1.Site
side of the neck is palpated at a time, the neck should
2.Number
be flexed to that side (i.e lateral flexion of the neck to
3.Size
that side).
4.Shape
5.Extent
6.Margin A.CERVICAL NODES
7.Surface
1.UPPER CIRCULAR GROUP
8.Discharge
9.Skin over the swelling
These neck nodes are palpated symmetrically by both
hands (i.e using right hand rt Side & lt hand for lt side)
2.CONDITION OF SKIN
in the following order from front to back:-
-Scar mark/ Scratch mark/ Yellow discolouration/ Ulcer/ 1.Submental
Ecchymosis/ Scaly/ Puncture mark/ Shiny 2.Submandibular
3.Tonsillar
3.CONDITION OF GUM 4.Preauricular
5.Postauricular
4.CONDITION OF MUCOUS MEMBRANE 6.Occipital
5.HEMORRHAGIC SPOTS IN SKIN 2.LATERAL CERVICAL NODES
1.Petechiae(1-2 mm in size i.e pin-head-size) Upper, middle & lower jugular nodes are palpated with
2.Purpura (2-5 mm in size) the palmar aspects of the middle 3 fingers at the
3.Ecchymoses=Bruises (Larger purpuric lesions) anterior border of sternomastoid, which may need to be
4.Suggillation ( > 20 mm in size) displaced posteriorly. The nodes in the posterior triangle
5.Haematoma (Large hemorrhages in the skin with (i.e spinal accessory & transverse cervical nodes) are
surface elevation) palpated with the palmar aspects of the middle 3 fingers
at the posterior border of sternomastoid.
II.PALPATION 3.ANTERIOR CERVICAL NODES
1.LYMPH NODE ENLARGEMENT Method of palpation of these nodes is usually not asked.
1.Site
2.Temperature
3.Tenderness

73
4.LOWER HORIZONTAL GROUP This group of lt side is palpated by rt hand & rt side by lt
hand. Pt sits on a stool & the examiner sits in front of
Includes scalene & supraclavicular nodes. For palpation the pt. At first the pt’s arm is slightly abducted & the
of scalene nodes, stand behind the pt. Ask the pt to flex extended fingers of the examiner’s hand are placed in
the neck towards the side (i.e to rt Or lt) under the axilla in such a way that the palm is directed
examination. Examine for the scalene nodes by dipping towards the chest. The pt’s arm is now brought to the
the palpating index finger behind the clavicle through side of her body & the forearm rests comfortably on the
the clavicular head of the sternomastoid. clinicians forearm. The other hand of the examiner is
placed over the pt’s same shoulder. Palpation is carried
>Neck nodes are examined in the following sequence so out by sliding the fingers upwards against the chest wall
that none is missed- to reach the highest limit of the axilla when the enlarged
1.Upper horizontal chain-Examine Submental, Subma- nodes are felt slipping out from the fingers.
ndibular, Tonsillar, Preauricular, Postauricular, Occi-
pital nodes. 5.APICAL GROUP (=INFRACLAVICULAR GROUP)
2.External jugular chain-Lies superficial to sternomas-
toid. The same method as described in central group is
3.Internal jugular chain-Examine the upper, middle & applied here, but the fingers are pushed as high as
lower jugular nodes. possible. If these nodes are very much enlarged, they
4.Spinal accessory chain may push themselves through the clavipectoral fascia to
5.Transverse cervical chain be felt through the pectoralis major just below the
6.Anterior jugular chain clavicle.
7.Juxtavisceral chain-Examine prelaryngeal, pretrach-
eal & paratracheal nodes. C.EPITROCHLEAR NODES
B.AXILLARY NODES Pt sits on a stool & the examiner stands in front of the
pt. Make the pt’s elbow slightly flexed & forearm
1.PECTORAL GROUP (=ANTERIOR GROUP) supinated while supporting the pt’s rt wrist with the
examiner’s lt hand & similarly pt’s lt wrist with the
This group is situated just behind the anterior axillary examiner’s rt hand. Now the pt’s lt elbow is grasped by
fold. Pt sits on a stool & the examiner sits in front of the the examiner’s lt hand & the pt’s rt elbow is grasped by
pt. The pt’s arm is elevated & using the rt hand for the the examiner’s rt hand. Now the nodes are palpated
lt side. Then fingers are insinuated behind the pectoralis under the thumb in the anteromedial region of lower
major. The arm is now lowered & made to rest on the part of the arm in between the groove of biceps &
examiner’s forearm. With the pulp of the fingers, try to brachioradialis muscle adjacent to the elbow. Both the
palpate the nodes. The palm should look forward. The sides should be examined one after another.
thumb of the same hand is used to push the pectoralis
major backwards from front so that nodes are palpated D.MEDIASTINAL NODES
between thumb & other fingers. Use the lt hand for the
rt side. Detected indirectly by percussion over the sternum.
Normally resonant note is obtained on percussing over
2.BRACHIAL GROUP the sternum.
(=LATERAL GROUP=HUMERAL GROUP)
E.PARA-AORTIC NODES
This group lies on the lateral wall of the axilla. Pt.’ sits
on a stool & the examiner sits in front of the pt.. Here Pt is in supine position. Pre-requisites are same as
Lt. hand is used for Lt. side & Rt. hand is used for Rt. described in abdominal palpation. In majority of the
side. The nodes are palpated with the examiner’s palm cases, abdominal lymph node lumps are found in
directed laterally against the upper part of the humerus. epigastrium, umbilical area & rt iliac fossa, but these
nodes may be present anywhere in the abdomen. These
3.SUBSCAPULAR GROUP (=POSTERIOR GROUP) nodes show no movements with respiration & there is
no mobility.
These nodes lie in the posterior axillary fold & are best
palpated from behind. Here lt hand is used for lt side &
rt hand is used for rt side. Pt sits on a stool. Standing
F.INGUINAL NODES
behind the pt, the examiner palpates the antero-internal
surface of the posterior axillary fold while with the other Pt is in supine position & thigh is extended. Palpate one
hand the pt’s arm is kept horizontally forward with after another over the horizontal chain, which lies just
flexion at the elbow. Now the nodes are palpated lying below the inguinal ligament & then palpate over the
on this surface with the palm of the examining hand vertical chain along the saphenous vein. Palpate both
looking backwards between thumb (at the back) & other the sides.
finger (in front).
G.POPLITEAL NODES
4.CENTRAL GROUP
Pt lies in supine position with the knee flexed to less
than 45 degree. These nodes are palpated with the
74
fingertips of both the examiner’s hands by curling the (press the upper part of shin bone-the anterior edge of
fingers into the popliteal fossa one after another as in the tibia i.e the portion of the leg between the ankle &
palpation of pulses in popliteal artery. knee) & frontal bone (press the forehead).
CONCLUSION
PERCUSSION
1.Palpate all the anatomical areas for lymph node
1.PERCUSSION OF STERNUM
enlargement.
2.In a pt with lymphadenopathy, examine Waldeyer’s
-Tympanic/ Dull
ring, breast, testis, non-pitting edema in legs, sternal
tenderness, hepatosplenomegaly, ascites, pleural
Flex your fingers to make a C shaped curve & then tap
effusion, tenderness in spine (paraplegia in a case of
the middle of the sternum with the tip of the fingers
lymphoma) & cranial nerves.
(forming C shaped curve) 1 to 2 times. In the presence
3.All the system should be examined.
of sternal tenderness, the Pt winces with pain or
4.In a pt with inguinal lymphadenopathy, examine the
complains of pain OR look to the face for facial
legs & sole of the foot for the presence of any ulcer,
grimacing.
infection etc.
5.A case of lymphoma may be given as superior
mediastinal syndrome. AUSCULTATION
6.No local examination is complete without the
examination of the lymph nodes draining the affected 1.D’ ESPINE’S SIGN
area.
Normally whispered voice sounds (Whispering
pectoriloquy) are well audible over the spines of the
2.LIVER lower cervical vertebrae in infancy & childhood & below
the 3rd thoracic vertebrae in adults. When whispering
1.Tenderness-Tender/ Nontender pectoriloquy is audible below these levels, D’ Espine’s
2.Palpable___cm/___fingers below the costal margin sign is said to be positive which is found in Enlarged
at rt mid-clavicular line (Measurement taken during mediastinal lymph nodes (at the bifurcation of trachea)
normal expiration) or tracheobronchial lymph nodes in lymphoma, mass in
3.Margin-Sharp (palm leaf)/ Rounded/ Irregular bronchogenic carcinoma, posterior mediastinal tumors &
4.Consistency-Soft/ Firm/ Hard central pneumonia.
5.Surface-Smooth/ Irregular/ Nodular
6.Moves with respiration
7.Left lobe-Enlarged/ Not enlarged
8.Upper border of liver dullness-Starts from rt ___ ICS
at MCL
LOCOMOTOR SYSTEM
9.Any pulsatin-Felt/ Not felt EXAMINATION (OPTIONAL)
3.SPLEEN
I.INSPECTION
1.Tenderness-Tender/ Nontender
2.Palpable___cm below the costal margin in rt MCL
1.MONO/ PAUCI/ POLY ARTICULAR
3.Consistency-Soft/ Firm/ Hard INVOLVEMENT
4.Notch-Felt/ Not felt
5.Surface-Smooth/ Nodular 2.ATTITUDE OF THE LIMB
6.Moves with respiration-Yes/ No
7.Inability to insinuate the fingers between the mass 3.SWELLING
& the costal margin
4.DEFORMITY
4.STERNAL TENDERNES
5.SIGNS OF INFLAMMATION OVER THE
-Present/ Absent INVOLVED JOINT
Flex your fingers to make a C shaped curve & then tap
the middle of the sternum with the tip of the fingers 6.WASTING OF MUSCLES
(forming C shaped curve) 1 to 2 times. In the presence
of sternal tenderness, the pt winces with pain or 7.SKIN CHANGES
complains of pain OR look to the face for facial
grimacing. II.PALPATION
5.TENDERNESS IN THE OTHER BONES 1.TEMPERATURE OF THE LOCAL PART
-Present/ Absent 2.TENDERNESS

When sternal tenderness is present, examine the pt for
tenderness in other bones like-Pelvic bones, long bones 3.ANY SWELLING

75
-Fluctuant/ Non fluctuant
4.MUSCLE POWER
5.CORROBORATION OF THE FINDINGS OF

INSPECTION
III.MOVEMENTS
1.RESTRICTED MOVEMENT/ EXCESSIVE
MOBILITY
2.ANY PAIN ON MOVEMENT
3.CREPITUS OR GRATING SENSATION ON

MOVEMENT
4.ANY ASSOCIATED MUSCULAR SPASM
IV.MEASUREMENT
1.LENGTH & CIRCUMFERENCE OF THE LIMB
2.MEASUREMENT IN RELATION TO VARIUS

BONY POINTS
V.EXAMINATION OF SPINE
1.TENDERNESS
2.MOBILITY
3.KYPHOSCOLIOSIS
4.GIBBUS
VI.GAIT
J.DIFFERENTIAL DIAGNOSIS
|DISEASE| |POINTS IN FAVOUR| |POINTS IN AGAINST|
K.PROVISIONAL DIAGNOSIS
L.SUMMARY
*Write only the history & positive findings

76
MEDICINE CASES
chest pain on affected side,Pt. can not talk,bronchial
breath sound,positive bronchophony and whispering
pectoriloquy,VF and VR are increased
A.CARDIOVASCULAR SYSTEM " Grave’s disease-
Tremor,tachycardia,exophthalmos(Sclera seen)
1. Mitral Stenosis-Ha-1390,Gol-143,Da-454
" Loud S1,Diastolic murmur 4. Pneumothorax (Rare)-Ha-1568,Da-570,Gol-296
" Examine CVS,Respiratory & Abdomen
5. TB/Miliary TB-Da-532,Gol-261
2. R H D " Hemoptysis-Gol-234
3. RHD with MS/AS/AR/MR/PHT/CCF 6. Empyema Thoracis (Rare)-Gol-310

" AR-Da-460,Gol-149
-Pistol shot sound,Corrigans pulse and diastolic 7. Hydropneumothorax (Rare)-Gol-299
murmur " Collapse-Gol-287
" MR-Gol-146,Ha-1393,Da-456 8. COPD (Chronic Bronchitis,Emphysema)-Ha-1551,Da-

509,Gol-249
"
7. Valvular Heart Disease (MS/MS/MR) 9. Bronchiectasis (Rare)-Da-521,Gol-238
4. Rheumatic Fever-Ha-1997 10. Lung Abscess-Da-520, Gol-258

" H/O sore throat, migratory polyarthritis involving " Interstitial pulmonary disease-Da-550
large joints and fever " Sarcoidosis-Da-552
" " Lumbar puncture-Gol-449,Da-1114
5. Bacterial Endocarditis/Infective Endocarditis- " Ryle’s tube feeding
" Ha-731,Da-463
" Fever for 6 months and features of aortic 11. Fibrosis of Lung (S) (Important)
regurgitation
" 12. Collapse of Lung (S) (Rare)
6. Fever of Unknown Origin-Ha-116,Gol-945
" Present as Malaria 13. Pleurisy (Rare)
"
14. Asthma (Rare)-Go-241
8. Heart Failure (Right side)
" CCF-Da-451,Gol-184-185 15. Pyopneumothorax
" Table-19.2 Da-900
16. Chronic Bronchitis with Acute Exacerbation
9. Pericardial Effusion (Rare)-Ha-1414,Da-479,Gol-
205,206-210 C.GASTROINTESTINAL SYSTEM
" Diffuse apex beat,2nd ICS on left side is dull on
percussion,heart sounds are distant,pulsus 1. Cirrhosis of Liver (ascites, portal hypertension)
paradoxus " portal hypertension-Ku-115,Gol-81,Ha-1863,Da-
" Pulmonary HTN-Gol-210,Da-501 850
10.Superior Venacaval Syndrome " Ha-1865,Da-848,852,8563,857,Gol-69
" Engorged veins in the anterior chest wall and neck " Ascires-Gol-75
11.Anemia hypoproteinemia " Alcoholic cirrhosis-Ha-1858
" PEM-Da-312 " Fig-5.23 Macleod-176
" Da-298,Da-902 "
" Anemia-Gol-325 2. Hematemesis & Melena(peptic ulcer, carcinoma of
" Lymphadenopathy-Gol-965 stomach, cirrhosis)
" Peptic ulcer-Da-782,Gol-17
B.RESPIRATORY SYSTEM " BL-1046,Da-764
" Features of upper GI bleeding-
1. Pleural Effusion(Isolated or with pulmonary HT) Hematemesis,melena,hyperactive bowel sounds,
(Important)-Ha-1565,Gol-302-310 elevated blood urea nitrogen level
" Sources of acute upper GI bleeding-1.Peptic
2. Consolidation (Found in pneumonia only)-Ku-235,D ulcer,2.Esophageal varices,3.Mallory-Weis
Sahoo-288 tear,4.Gastro duodenal erosions,5.Malignancy-
Carcinoma of stomach
3. Pneumonia (isolated or complicated with empyema or 3. Typhoid (Rare)-Gol-945
pleural effusion)Ha-808,1530,Da-526,531,561,Gol-254 " Diarrhea for 25 days,splenomegally,high grade
" Lt. lower lobe pneumonia in early consolidation continuous fever
phase,may be pneumococcal in origin
" Fever of high grade with chills and rigor,severe 4. TB. Abdomen (Important)-Gol-34
77
" Chronic cough for 6 month,pain while defecating,
marked loss of appetite 3. ARF (S)
5. Viral hepatitis (usually Hep B)-Ha-1822,Da- 4. CRF (S)

838,860,Gol-51
" Jaundice,hepatomegally,loss of appetite 5. Diabetic Nephropathy (Rare)
" D/D-ALA,hemolytic jaundice,alcoholic hepatitis,
CCF,acute malaria,chronic hepatitis,drug induced F.LYMPHORETICULAR SYSTEM
hepatitis,Weil’s disease,Infectious mononucleosis
1. Hodgkin Lymphoma (Rare)
6. Drug induced Gastritis (Rare)
" H/O drug intake,hematemesis and melena 2. Non-Hodgkin Lymphoma (Rare)
" Erosive gastritis due to analgesic intake
3. Sickle cell Anemia
7. Hepatosplenomegaly-Gol-83,378
" Jaundice-Gol-62 4. Thalassemia (Rare)
" Rey’s syndrome
5. Leukemia (Rare)
8. Liver abscess (Rare)-Ha-752,Da-878,S Das Text-
G.MUSCULOSKELETAL SYSTEM
9.Peritonitis
1. SLE (S)/(L)
D.NERVOUS SYSTEM
2. Reactive Arthritis (S)-Seronegative
0. Meningitis-Bacterial/Viral/Tubercular -HA-2471,DA-
1193.GOL-627 3. Leprosy (S) (Rare)
4. Polymyositis (S) (Rare)

1. TB Meningitis (isolated or with Facial palsy)
5. Rheumatoid arthritis (S) (Rare)
2. CVA/Hemiplegia (with any cranial nerve affected
especially facial palsy & 3rd nerve palsy)-Da-1159,Gol- 6. Pyomyositis (S) (Rare)
491
" In all hemiplegic patient,Cvs examination is a must
" Left sided hemiplegia in stage of recovery due to H.POISONING
cerebral thrombosis probably involving
lenticulostriate branch of MCA and the lesion is in 1. Organophosphorous Poisoning
the internal capsule.
" Muscle weakness-Da-986 2. Oleander Poisoning
" Causes of polyarthritis-Da-976
3. Snake Bite Poisoning
3. Encephalitis (Viral most common) (Rare)-Ha-2480,
Da-1197, Gol-637 4. Datura Poisoning
5. Organochlorine Poisoning
4. Paraplegia-Ha-
5. GBS (Important)
6. Malaria-Complicated/Uncomplicated
7. Facial palsy (Bell’s palsy)
8. Diabetic Neuropathy (S)
9. Peripheral Neuropathy
10. Quadriparesis/Quadriplegia (Rare)
11. Motor Neuron Disease (MND)
E.GENITOURINARY SYSTEM
1. Nephrotic Syndrome (S)
2. Acute Glomerulonephritis (S)

78
4.VOMITING
SURGERY HISTORY TAKING
A. 1.Duration
2.Onset
1.NAME 3.Progress
2.AGE 4.Episodes
3.RELIGION 5.Projectile
4.SEX 6.Nausea
7.Timing
5.FROM 8.Relieving factors
6.OCCUPATION 9.Aggravating factors
B.CHIEF COMPLAINTS
VOMITUS
1.
1.Amount
2.Colour
2.
3.Bilious
4.Blood Stain
3.
5.Recent Food
6.Foul Smelling
4.
5. DIARRHEA
C.HISTORY OF PRESENT 1.Duration
ILLNESS 2.Onset
3.Progress
4.Episodes
1.ACUTE ABDOMEN 5.Timing
6.Relieving factors-Drug
1. ABDOMINAL PAIN 7.Aggravating factors-Pain/Food
1.Site MOTION
2.Duration 1.Amount
3.Onset-Gradual/Sudden 2.Colour
4.Time of onset(Timing) 3.Blood stained/ Mucous stained
5.Character(Type) 4.Solid/ Watery
6.Progression 5.Tenesmus
7.Severity 6.Foul smelling
8.Frequency & Periodicity 7.Floating in Pan
9.Movement of pain-Shifting/Radiation/Referal
10. Lasting 6.CONSTIPATION
11. Aggravating factors-Food/Vomiting/Respiration/
Posture/Micturition/Jolting/Walking/Defecation/Pres- 1.Duration
sure 2.Onset
12. Relieving factors-Food/Vomiting/Drug 3.Progress
13. Associated Symtoms 4.Relieving factors-Drug
5.Aggravating factors-Pain/ Food
2. ABDOMEN DISTENSION
7.SWELLING
1.Duration
2.Onset 1.Duration
3.Progress 2.Onset
4.Relieving factors 3.Progress
5.Aggravating factors 4.Site
5.Size
3. DYSPHAGIA 6.Surface
7.Skin over it
1.Duration 8.Edge
2.Onset 9.Extension
3.Progress
4.More to-Solid/Liquid 8.HEMATEMESIS
6.Relieving factors-Drug/Lying down 1.Duration
2.Onset
3.Frequency
4.Quantity
79
5.Progress 5.Paroxysm-One/ Multiple
6.Colour-Bright red(fresh)/Dark red(altered) 6.Grade-High /Low
7.Mixed with Food Particle 7.Chills/ Rigor
8.Aggravating Factors 8.Diurnal Variation-How long the fever stays-
9.Relieving Factors 9.H/O convulsion
10. H/O Previous dyspepsia/Upper GI bleeding 10. H/O drug intake
11. H/O Alcohol abuse 11. H/O any treatment received & its effect-
12. H/O Recent intake of corticosteroids/NSAID
13. Retching preceeding hematemesis 13. OLIGURIA
14. Blood staining of the vomitus is apparent in first
vomitus 1.Duration
2.Onset
9. EDEMA 3.Daily Amount
4.Urine Colour
1.Site-Face/ Leg 5.Dysuria
2.Duration 6.Hematuria
3.Onset 7.Aggravating Factors
4.Progress 8.Relieving Factors
5.Pitting/ Non-pitting
6.Aggravating Factors-Oliguria 14.RECTAL BLEEDING (HEMATOCHEZIA)
7.Relieving Factors-Diuretic
1.Duration
2.Onset
10. JAUNDICE 3.Frequency
4.Quantity
2.Onset 6.Colour-Bright red (fresh)/ Dark red (altered)
3.Progress 7.Mixed with Food Particle
4.Appetite 8.Aggravating Factors
5.Weight loss 9.Relieving Factors
6.Urine Colour
7.Stool Colour 15. ANOREXIA
8.Skin Itching
9.I.V Injection/ Tattooing/ Sexual intercourse 1.Duration
10. H/O Drug abuse/ Alcohol intake 2.Associated Weight loss
11. H/O Blood Transfusion
12. Associated with-Fever/ Chill & Rigor/ GI bleeding/ 16. WEIGHT LOSS
Abdominal pain/ Altered Bowel habit
13. H/O travel & immunization-HBV/ HAV 1.Duration
14. Aggravating Factors 2.Onset
15. Relieving Factors 3.Progress
4.Amount
11. MELENA[TARRY(STICKY) BLACK STOOL]
17. BONE PAIN
1.Duration
2.Onset 1.Duration
3.Frequency 2.Onset
4.Quantity 3.Progress
5.Progress 4.Tenderness
6.Associated with straining 5. Aggravating factors
7.Loose/ Semisolid 6.Relieving factors
8.Associated symptoms-Vertigo/ Dizziness/ Syncopal
attack during defecation 18.BLEEDING DIATHESIS
9.Aggravating Factors
10. Relieving Factors 1.Duration
2.Onset
12. FEVER 3.Progress
* Rule out MALIGNCY--16, 17 & 18
1.Duration
2.Onset 19. FATIGUE/WEAKNESS
3.Type-
• Continued 1.Duration
• Remittent 2. Onset
• Intermittent-Quotidian/ Tertian/ Quatran 3. Progress
4.Progress 4. Aggravating factors
80
5.Relieving factors • Colour
6.Recent weight loss • Blood stained
• Mucous stained
7.Muscle cramp • Solid/ Watery
• Tenesmus
2.CHRONIC ABDOMEN • Foul smelling
• Floating in Pan
1.ABDOMINAL PAIN
6.CONSTIPATION
• Site • Duration
• Duration • Onset
• Onset-Gradual/ Sudden • Progress
• Time of onset (Timing) • Relieving factors-Drug
• Character (Type) • Aggravating factors-Pain/ Food
• Progression
• Severity 7.SWELLING
• Frequency & Periodicity
• Movement of pain-Shifting/ Radiation/ Referal • Duration
• Lasting • Onset
• Aggravating factors-Food/ Vomiting/ Respiration/ • Progress
Posture/ Micturition/ Jolting/ Walking/ Defecation/ • Site
Pressure • Size
• Relieving factors-Food/ Vomiting/ Drug • Surface
• Associated Symtoms • Skin over it
• Edge
2. ABDOMEN DISTENSION • Extension
• Duration 8.HEMATEMESIS
• Onset
• Progress • Duration
• Relieving factors • Onset
• Aggravating factors • Frequency
• Quantity
4.VOMITING • Progress
• Colour-Bright red (fresh)/ Dark red (altered)
• Duration • Mixed with Food Particle
• Onset • Aggravating Factors
• Progress • Relieving Factors
• Episodes • H/O Previous dyspepsia/ Upper GI bleeding
• Projectile • H/O Alcohol abuse
• Nausea • H/O Recent intake of corticosteroids/ NSAID
• Timing • Retching preceeding hematemesis
• Relieving factors • Blood staining of the vomitus is apparent in first
• Aggravating factors vomitus
VOMITUS 9. EDEMA
• Amount
• Colour-Bilious/ Blood Stained • Site-Face/ Leg
• Recent Food • Duration
• Foul Smelling • Onset
• Progress
5. DIARRHEA • Pitting/ Non-pitting
• Aggravating Factors-Oliguria
• Duration • Relieving Factors-Diuretic
• Onset
• Progress 10.YELLOW COLOURATION (JAUNDICE)
• Episodes
• Timing • Duration
• Relieving factors-Drug • Onset
• Aggravating factors-Pain/ Food • Progress
• • Appetite
MOTION • Weight loss
• Amount • Urine Colour
• Stool Colour
81
• Skin Itching 15. ANOREXIA
• I.V Injection/ Tattooing/ Sexual intercourse
• H/O Drug abuse/ Alcohol intake • Duration
• H/O Blood Transfusion • Associated Weight loss
• Associated with-Fever/ Chill & Rigor/ GI bleeding/
Abdominal pain/ Altered Bowel habit 16. WEIGHT LOSS
• H/O travel & immunization-HBV/ HAV
• Aggravating Factors • Duration
• Relieving Factors • Onset
• Progress
11. MELENA [ TARRY i.e. STICKY BLACK STOOL] • Amount
• Duration 17. BONE PAIN

• Onset
• Frequency • Duration
• Quantity • Onset
• Progress • Progress
• Associated with straining • Tenderness
• Loose/ Semisolid • Aggravating factors
• Associated symptoms-Vertigo/ Dizziness/ Syncopal • Relieving factors
attack during defecation
• Aggravating Factors 18.BLEEDING DIATHESIS
• Duration
12. FEVER • Onset
• Progress
• Duration * Rule out MALIGNCY--16, 17 & 18
• Onset
• Type- 19. FATIGUE/WEAKNESS
1. Continued
2. Remittent • Duration
3. Intermittent-Quotidian/ Tertian/ Quatran • Onset
• Progress • Progress
• Paroxysm-One/ Multiple • Aggravating factors
• Grade-High /Low • Relieving factors
• Chills/ Rigor • Recent weight loss
• Diurnal Variation-How long the fever stays- • Muscle cramp
• H/O convulsion
• H/O drug intake 20.FLATULENT DYSPEPSIA
• H/O any treatment received & its effect-
21.BOWEL HABIT
13. OLIGURIA
• Duration 3.ABDOMINAL LUMP

• Onset
• Daily Amount *As in acute & chronic abdomen
• Urine Colour
• Dysuria
•
•
Hematuria
Aggravating Factors 4.HERNIA
1.PAIN
14.RECTAL BLEEDING (HEMATOCHEZIA)
1.Site
• Duration 2.Duration
• Onset 3.Onset-Gradual/Sudden
• Frequency 4.Time of onset/ Timing
• Quantity 5.Character/Type
• Progress 6.Progression
• Colour-Bright red (fresh)/ Dark red (altered) 7.Severity
• Mixed with Food Particle 8.Frequency & Periodicity
• Aggravating Factors 9.Movement of pain
• Relieving Factors Shifting
Radiation
Refferal

82
10. Lasting 2.Loss of wt & cachexia
11. Aggravating factors-Food/Vomiting/Respiration/ 3.Various types of indigestion
Posture/Micturition/Jolting/Walking/Defaecation/Pr
essure
12. Relieving factors- Food/vomiting/Drug 7.LUMP
13. Associated Symtoms
1.Duration
2.LUMP 2.Mode of onset
3.Other associated symptoms
1.How it started–Straining/ Laughing/ Lifting wt • Difficulty in respiration
2.Where it 1st appeared–In the groin/ Below the groin • Difficulty in swallowing
3.Size of the hernia when it was 1st seen- • Interfering with any movement
4.It disappears automatically on lying down 4.Pain
5.Systemic symptoms-Absent/Colicky abdominal Pain/ • Nature
Vomiting/abdominal distension/absolute constipati- • Site
on • Time of onset
6.Other complaints-Persistent Coughing/ Constipation/ 5.Progress of the swelling-Change in size
Frequency or Urgency of micturition 6.Exat site
7.Fever
8.Presence of other lump
5.SCROTUM 9.Secondary changes
• Softening
6.RECTUM
• Ulceration
• Fungation
• Inflammatory changes
1.BLEEDING 10. Impairment of function
11. Recurrence of swelling after removal
1.Amount of bleeding 12. Loss of wt
2.Color of the bleed
8.THYROID
• Bright red–Rectum/ Anal canal
• Dark red–Ascending/ Transverse/ Descending /
Sigmoid colon
• Black –Upper GI bleeding/ Sall intestine or higher 1.SWELLING
3.Relation of blood with feces
• Blood mixed with feces - Higher than sigmoid 1.Onset
colon 2.Duration
• Blood on the surface of the feces – Rectum / Anal 3.Rate of growth
canal 4.Associated with pain or not
• Blood separate from the feces – Bleeding 5.How does the pt sleep at night-Does she spend
Carcinoma of rectum sleepless nights
• Blood in the toilet paper - Minor bleeding from 6.Pt.is-Very worried/stressed or strained
the anal skin / External hemorrhoids
4.Discharge of pus / Mucus 2.PAIN
2.PAIN 3.PRESSURE EFFECTS
1.Nature – throbbing / sharp cutting / intermittent –Dysphagia/ Dyspnea / Hoarseness of voice/Stridor

2.Relation with defecation – occurs with defecation /
after defecation 4.SYMPTOMS OF PRIMARY THYROTOXICOSIS
3.ABNORMALITY IN THE BOWEL HABIT 1.Loss of wt inspite of good appetite

2.Preference for cold & intolerance to heat
–Increasing constipation/sensation of incomplete 3.Excessive sweating
evacuation after defecation / spurious morning 4.Nervousexcitability/Irritability/ Insomnia/Tremor of
diarrhea/pipestem or tape-like stool / tenesmus hands / Weakness of muscles
5.Staring or protruding eyes / Difficulty in closing her
4.PROLAPSE eyelids / Double vision or Diplopia/ Ophthalmople-
gia/Edema or Swelling of the conjunctiva
a.Present / Absent
b.Prolapse coming out during defecation is 5.SYMPTOMS OF PRIMARY THYROTOXICOSIS
reduced automatically/Replaced by pushing it in
–Ppalpitation/Ectopic beats/ Cardiac arrhythmia/
5.OTHER COMPLAINTS Dyspnea on exertion/ Chest pain
1.Pruritus ani
83
6.SYMPTOMS OF MYXEDEMA 2.Previously operated- yes/no
–Increased wt despite poor appetite/ Intolerance of cold

weather & preference for warm climates/ Dry skin 3.LUMP
1.H/O similar swelling/Recurrence of swelling
9.BREAST
1.LUMP
4.THYROID
1.Mode of onset – sudden / gradual 1.Course of past treatment & its effect
2.Duration
3.Rate of growth-Slow/Rapid E.PERSONAL HISTORY
2.PAIN – yes / no • Occupation
• Socioeconomicstatus-Poor/Average/High income
3.DISCHARGE FROM NIPPLE status
• Marital status-Married/Unmarried/Widow/ Divorced/
4.RETRACTION OF NIPPLE Separated
• Dietary habit-
5.LOSS OF WT 1.Regular/Irregular/Fasting/Avg.Indian diet
2.Vegetarian/Non-vegetarian
10.ULCER • Addiction
1.Alcohol-a.Amount/ day- b.Duration-
2.Smoking- a.Nos- b.Duration-
1.Mode of onset – trauma / spontaneously 3.Tobacco in any form
2.Duration - long / short • Bowel
3.Painful / pain less • Bladder
4.Associated disease-Nervous disesse / TB / Diabetes • Allergies
/ nephritis
MENSTRUAL HISTORY
11.LYMPHATICS
I.PRESENT CYCLE
1.Duration a.Age of menarche

2.Which group 1st affected b.LMP(First day of the last normal menstrual period)
3.Pain c.Duration of bleeding
4.Fever d.Length of the cycle(It is the interval from the first day
5.Primary focus of one period to the onset of the next period)
6.Anorexia e.Regularity of the cycle(Rhythm)-Regular/Irregular
7.Wt. loss f.Associated clot
8.Pressure effects-Swelling of face & neck/Edema & g.Associated pain
Venous congestion of lower or upper limb/Dyspnea/
Dysphagia II.PREVIOUS CYCLES
D.PAST HISTORY a.Duration of bleeding

b.Length of the cycle(It is the interval from the first day
of one period to the onset of the next period)
1.Similar attack history in Past
c.Regularity of the cycle(Rhythm)-Regular/Irregular
2.No history suggestive of TB,HTN,Diabetes,IHD
d.Associated clot
3.Prolonged illness in the past
e.Associated pain
4.Serious illness in the past
>Mention about past menstrual history only if previous
cycles are irregular.Otherwise tell-Previous cycles are
1.ACUTE ABDOMEN regular.
>Typical description-Menstrual period is 2-3 days in a
1.Pain cycle of 28-30 days duration,regular,not associated
2.Hematemesis and Melena with pain & clot. OR Menstrual period is 2-3 days in a
3.History of similar previous attack cycle of 28-30 days duration,regular & with average
4.H/O of high rise of temp and jaundice blood flow.(Average blood flow indicates it is not
associated with clot)
2.HERNIA >Clot in menstrual flow indicates heavy bleeding. It can
also be determined by number of pads used.
1.Previous history of hernia repair on same side

84
F.FAMILY HISTORY -Normal/Sluggish/ No movement with respiration-
Generalised/ Localised
1.Similar history in the family-Y/N
2.History of cancer
5.VISIBLE PERISTALSIS
2.No history suggestive of TB,HTN,Diabetes,IHD
-Present/ Absent
G.TREATMENT HISTORY
6.PULSATILE SWELLING
1.Effect of local medication -Present/ Absent
2.Course after admission- Improving/Worsening/
Complication 7.SKIN
3.Any chronic medication-Antidiabetic/Antihypertensive/
Warfarin
• Localised redness
4.Blood transfusion history
• Grey Turner sign (Bluish discolouration of flanks)
5.Allergy to any drugs
-Present/ Absent
6.Any operation/Hospitalisation
• Cullen sign (Bluish discolouration of umbilicus)
-Present/ Absent
I.GENERAL EXAM.
8.VISIBLE VEINS OVER
1.He is Conscious cooperative & well oriented
2.Body built-Patient is adequately built -Anterior abdominal wall/ Around umbilicus
3.Nutrition-Moderate/Undernutrition/Obese*moderately
Nourished 9.ANY SCAR MARK
4.Decubitus-Calm&quiet/Lying still/Rolls on bed
5.Facies-Normal/Toxic(Dehydrated)/Ill/Anxious
6.Pallor … B.PALPATION
7.Icterus
8.Cyanosis-Peripheral/Central 1.HYPERAESTHESIA
9.Engorgement of neck veins-Raised JVP_ cm
10. Lymph Node Enlargement-Cervical/Axillary/Inguinal >This can be elicited by gently picking up a fold of skin
11. Thyroid Swelling-a.Size- b.Shape- c.Thrill- & lifting it off the abdomen or by simply scratching the
12. Clubbing-Drum stick type/Parrot beak type abdominal wall with finger.
13. Koilonychia >Hyperaesthesia of the Sherren’s triangle (this is
14. Edema of dependent parts formed by lines joining umbilicus, right anterior superior
15. Condition of skin-Itching mark iliac spine & symphysis pubis) is found in acute
16. Any visible deformity of-skull/spine/limbs/swelling of appendicitis (gangrenous appendicitis).
abdomen >BOAS’S SIGN-It is an area of hyperaesthesia between
17. VITALS
9th & 11th ribs posteriorly on the rt side & is suggestive
• PULSE
of acute cholecystitis.
• BLOOD PRESSURE
• RESPIRATION
2.TENDERNESS
• TEMPERATURE
A.LOCALISED TO/ GENERALISED
J.LOCAL EXAMINATION Ask the pt to show the tender area. If he is not definite
about it, ask him to cough & find out the area where a
1.ACUTE ABDOMEN sharp twinge of pain is felt during coughing. Note the
extent & degree of tenderness. Percuss the abdomen in
doubtful cases to detect tenderness over the inflamed
A.INSPECTION organ.
1.INSPECTION OF HERNIAL ORIFICES- B.SPREAD
Inguinal/ Femoral/ Other
C.REBOUND TENDERNESS
2.CONTOUR OF THE ABDOMEN
>Palpate the suspected area & with each respiration
-Scaphoid/ Distended press the hand down on the abdomen gradually as the
circumstances will allow. The hand is then withdrawn
3.UMBILICUS suddenly & completely. In a positive case, pt will wince
with pain.
-Inverted/ Everted/ Shifted >This is mainly a sign of peritonitis due to presence of
an inflamed organ underneath it.
4.MOVEMENT WITH RESPIRATION

85
>Presence of rebound tenderness in acute intestinal
obstruction indicates strangulation of gut.
C.PERCUSSION
1.TENDERNESS
D.BED-SHAKING TEST (BAPAT)
It is elicited by light percussion as mentioned
Move the foot end of the bed & this will evoke pain at previously.
the position of the inflamed organ.
2.SHIFTING DULLNESS
E.DIFFERENTIATION FROM THORACIC DISEASE
3.OBLITERTION OF LIVERDULLNESS
F.TESTS TO ELICIT TENDERNESS
a.ROVSING’S SIGN D.AUSCULTATION

When the lt iliac fossa is pressed, pain is felt in the rt 1.BOWEL SOUND-RIF/ LIF/ RH/ LH
iliac fossa in case of acute appendicitis. :___ /minute
b.COPE’S PSOAS TEST

E.OTHER EXAMINATION
Turn the pt to lt lateral position & hyperextend (move
backward) the rt thigh. This will stretch the Psoas major 1.RECTAL EXAM
muscle which in turn will initiate pain in case of
retrocecal appendicitis. 2.VAGINAL EXAM
c.OBTURATOR TEST
2.CHRONIC ABDOMEN
Pt lies supine. Slightly flex the rt knee & rt thigh. Then
internally rotate the rt thigh. This will stretch the A.INSPECTION
Obturator internus muscle which in turn will initiate pain
in case of appendicitis of peivic type of appendix.
1.SKIN & SUBCUTANEOUS TISSUE
d.BALDWING’S TEST
2.UMBILICUS
Place your hand over pt’s flank. Then ask the pt to raise
his rt lower limb off the bed keeping the knee extended. 3.CONTOUR OF THE ABDOMEN
This will initiate pain in case of retrocecal appendicitis.
4.MOVEMENTS
3.MUSCLE RIGIDITY
• Respiration
4.DISTENSION • Peristaltic
• Other
Central distension of abdomen is found in case of acute
intestinal obstruction wherein the coils of intestine are 5.SWELLING
felt to harden & soften alternatively. Generalised
distension of abdomen is a late feature of general Refer to abdominal examination in medicine.
peritonitis.
5.LUMP
B.PALPATION
1.TENDER SPOT
Carefully palpate the lump noting its position, size,
shape, consistency & mobility.
• Localised to- / Generalised
• Degree of tenderness-Mild/ Moderatel/ Servere
6.PALPATION OF HERNIAL SITES
• Murphy’s Sign
7.ORGANOMEGALY
• Liver 2.FLUID THRILL
• Spleen
• Kidney 3.PALPATION OF ABDOMINAL ORGAN
8.PER RECTAL EXAMINATION
• Stomach-succussion splash
9.FLUID THRILL • Liver
• Spleen
• Gall balder
10.SUCCUSSION SPLASH
• Kidneys

86
C.PERCUSSION B.PALPATION
1.SHIFTING DULLNESS 1.LOCAL TEMPERATURE
D.AUSCULTATION Local rise of temperature indicates inflammatory

swelling.
1.BOWEL SOUND- RIF/LIF/RH/LH
2.TENDERNESS
2.VENUS HUM/ KENWAY’S SIGN
Tenderness indicates inflammatory swelling.
E.EXAMINATION OF LEFT SUPR- 3.a.POSITION

b.SIZE
ACLAVICULAR LYMPH NODES c.SHAPE
d.SURFACE
F.PER RECTAL EXAMINATION
4.MARGIN
G.VAGINAL EXAMLNATION -Well-defined & distinct/ Ill-defined
H.OTHER EXAMINATION Well-defined & distinct margin is a feature of neoplasm

while ill-defined margin is a feature of inflammatory &
1.EXAM.OF CHEST FOR-Pleuricy/Angina pectoris/ traumatic swelling.
Coronary thrombosis/Pericarditis/Fibrosis of
intercostals muscles 5.CONSISTENCY
2.EXAM. OF SPINE FOR-Pott’s disease/Extradural
abscess -Soft/ Cystic/ Firm/ Hard
-Consistency throughout the swelling-Same/ Variable
-Cystic swelling
• Fluctuation-Present/ Absent
• Fluid thrill-Present/ Absent
3.ABDOMINAL LUMP -Swelling pits on pressure-Yes/ No
A.INSPECTION 5.MOVEMENT
• Swelling moves with respiration-Yes/ No

1.CONDITION OF THE SKIN OVER THE
If the swelling moves vertically with the respiration,
SWELLING then it is obviously an intra-abdominal swelling.
• Swelling is movable in all direction or restricted in a
-Tense/ Red/ Shining/ Pigmented/ Engorged veins particular direction
• Swelling is ballotable-Yes/ No
2.a.POSITION
b.SIZE 6.PARIETAL/INTRABDOMINAL
c.SHAPE
A.RISING TEST
3.MOVEMENT WITH RESPIRATION
Ask the pt to fold his arms over the chest & then raise
Swelling arising from the liver, gall bladder, stomach & his shoulders from the bed to make the abdominal
spleen move with respiration. muscles taut. If the swelling is parietal, then it will be
more prominent & will be freely movable over the taut
4.VISIBLE PERISTALSIS muscle. If the swelling is parietal but fixed to the
abdominal muscles, then the swelling will not be
Visibile peristalsis found in carcinoma of the pylorus of movable. If the swelling disappears or becomes
the stomach is from lt to rt while visible peristalsis found smaller, then the swelling is an intra-abdominal one.
in the carcinoma of the transverse colon is from rt to lt.
B.LEG LIFTING TEST (CARNETT’S TEST)
5.THE HERNIAL SITES
Ask the pt to raise the leg with knee extended from
the bed to make the abdominal muscles taut. If the
6.THE SCROTUM
swelling is parietal, then it will be more prominent &
will be freely movable over the taut muscle. If the
7.LEFT SUPRACLAVICULAR LNS swelling is parietal but fixed to the abdominal
muscles, then the swelling will not be movable. If the

87
swelling disappears or becomes smaller, then the the swelling goes right down to the bottom of the
swelling is an intra-abdominal one. scrotum (congenital type) or stops just above the testis
(funicular & acquired varieties). Femoral hernia extends
C.VALSALVA MANEUVER from below the inguinal ligament & ascends over it.
Ask the pt to blow out with nose & mouth shut to c.VISIBLE PERISTALSIS
make the abdominal muscles taut. This maneuver is
particularly done when a swelling is found on the -Present/ Absent
flank, while rising test & leg lifting test are done when
a swelling is found on the anterior abdominal wall. Peristalsis may be seen if the covering is thin as in
recurrent hernia. Visible peristalsis is never seen in
7.SWELLING IS PULSATILE femoral hernia.
-No/ Yes-Transmitted/ Expansile 2.SKIN OVER THE SWELLING
>Put your index finger of both hand side by side over -Normal/ Reddened/ Discolored/ Streaks of brown
the swelling. With each pulsation, the 2 fingers will be pigmentation/ Wrinkled/ Scar
diverted if the pulsation is expansile whereas the fingers
will not be diverted in transmitted pulsation. 3.IMPULSE ON COUGHING
>Alternatively, place the pt in knee-elbow position.
Aswelling in front of the aorta will be separated from the -Expansile/ No response
aorta & will become non-pulsatile, whereas an aneurysm
will continue to pulsate. >Ask the pt to stand up, turn his face away from the
clinician & cough. Look at the superficial inguinal ring. If
8.SWELLING AT HERNIAL SITES a swelling already exists, then it will expand during
coughing (expansile cough impulse) as more abdominal
-Yes/ No contents will be driven into the hernial sac due to raised
intra-abdominal pressure. If there was noswelling
9.PALPATION OF initially, then a momentary bulge is seen synchronously
• LIVER with the act of coughing.
• SPLEEN >Presence of expansile cough impulse is almost
• KIDNEY diagnostic of a hernia, but its absence doesn’t exclude
a diagnosis of hernia, because, when the neck of the sac
is blocked by the adhesions, additional viscera will not
C.PERCUSSION enter into the sac during coughing.
1.PERCUSSION NOTE 4.POSITION OF THE PENIS
-Tympanitic/ Dull -Central/ Pushed to-Rt/ Lt
2.SHIFTING DULLNESS B.PALPATION

-Present/ Absent 1.POSITION & EXTENT
4.HERNIA If the swelling descends into the scrotum, then it is

obviously an inguinal hernia. An inguinal hernia is
positioned above the inguinal ligament & medial to the
A.INSPECTION pubic tubercle, whereas a femoral hernia lies below the
inguinal ligament & lateral to the pubic tubercle. But a
1.SWELLING large femoral hernia ascends superficial to the inguinal
ligament though its base still lies below the inguinal
a.SIZE & SHAPE ligament. In obese pts follow the sdductor longus
tendon upwards to reach the pubic tubercle as it is very
An indirect hernia is pyriform in shape, with a stalk at difficult to feel the pubic tubercle in these pt.
the external inguinal ring & usually extends down into
the scrotum. A direct hernia is spherical in shape & 2.GET ABOVE THE SWELLING
shows little tendency to enter into the sctrotum.
Femoral hernia is spherical in shape ssrting from below –Can/ Can’t
& lateral to the pubic tubercle.
This test differentiates a scrotal swelling from an
b.POSITION & EXTENT inguinal swelling. Hold the root of the scrotum between
the thumb in front & other fingers behind in an attempt
Inguinal hernia extends from above the inner part of the to reach above the swelling. It is impossible to get
inguinal ligament down to the scrotum. Note whether above the swelling in case of inguinal hernia, whereas in

88
case of a pure scrotal swelling, nothing is felt between
the fingers except the structures within the spermatic
B.PALPATION
cord. This test is not used for femoral hernia as femoral
hernia doesn’t produce scrotal swelling. 1.SKIN
3.CONSISTENCY 2.SWELLING
-Doughy & granular/ Elastic/ Tense & tender a.FLUCTATION

b.TRANSLUSCENCY
Omentocele or epiplocele feels doughy & granular while c.REDUCIBILITY
enterocele feels elastic. A strangulated hernia feels d.IMPULSE ON COUGHING
tense & tender.
3.TESTIS
4.RELATION OF THE SWELLING TO THE
TESTIS & SPERMATIC CORD 4.EPIDYMIS
Inguinal hernia remains in front & sides of the spermatic
5.SPERMATIC CORD
cord & testes which remain incorporated in the swelling.
In acquired or funicular variety, the hernia stops just
above the testis which can be felt apart from the hernia. 6.LYMPHNODES
5.IMPULSE ON COUGHING C.OTHER EXAMINATION

• Root of scrotum held between thumb 1.Rectal exam.
& index finger 2.Chest exam.
• Zieman’s technique 3.Kidney exam
6.REDUCIBLE
6.RECTUM
-Yes/ No
A.INSPECTION
7.INVAGINATION TEST
Extensive ulcer with everted margin-Anal carcinoma
8.RING OCCLUSION TEST
B.PALPATION
9.IN CASE OF A CHILD
1.DIGITAL RECTAL EXAMINATION
C.PERCUSSION
Rectal Examinition – Lt Lateral position
D.AUSCULTATION 1.Within the lumen

2.In the wall
E.EAXM OF TESTIS, EPIDIDYMIS 3.Out side the wall
& SPERMATIC CORD • Anteriorly
• Laterally
• Posteriorly
F.EXAMINATION OF THE TONE 4.At the end of the rectal examination always look
OF THE ABDOMINAL MUSCLE at the examining finger for the presence of feces /
blood / pus / mucus
G.PER RECTAL EXAMINATION C.ABDOMINAL EXAMINATION

5.SCROTUM 1.Indistinct lump at the Lt. side of the abdomen
2.Liver – for secondary metastasis
I.LOCAL EXAMINATION 3.Note – jaundice / hard subcutaneous nodules / free
fluid in the abdomen
A.INSPECTION D.LYMPH NODES

1.Skin & subcutaneous tissue
1.Iliac LNs–Hind gut (by deep palpation) Inguinal LNs-
2.Swelling
Below the pectinate line
3.Impulse on coughing

89
7.LUMP G.EXAMINATION FOR PRESSURE
EFFECT
A.INSPECTION
1. SITE
8.THYROID
2. NUMBER
3. SIZE A.INSPECTION
4. SHAPE
5. EXTENT 1. PIZZILLO’S METHOD
6. MARGIN 2. MOVEMENTS WITH SWALLING
7. SURFACE 3. RAISE BOTH ARMS OVER HIS HEAD TILL
8. DISCHARGE THEY TOUCH EARS
9. SKIN OVER THE SWELLING 4. MOVEMENTS WITH PROTRUSION OF
TONGUE
B.PALPATION
B.PALPATION
1. TEMPERATURE
2. TENDERNESS 1.GENERAL
3. SIZE
1.By flexing neck to forward & to side
4. SHAPE
2.By extending neck
5. EXTENT
3.Lahey’s Method
6. SURFACE 4.Criles Method
7. MARGIN 5.Result
8. CONSISTENCY 4.Whole thyroid gland is involved - Yes/ No
9. MOBILITY 5.Localised swelling-Position-Size- Shape-
10.RELATION TO ADJACENT & DEEP Extent- Consistency-
STRUCTURE 6.Mobility
11.PULSATION-TRANSMITTED/EXPANSILE 7.To get below the thyroidgland-can/can not
8.Pressure effect – Kocher’s test
12. FLUCTUATION
• Large swelling
• Freely movable swelling 2.FEEL FOR CAROTID PULSATION
• Small swelling
• Very Small swelling-PAGET TEST 3.HORNER’S SYNDROME
13.REDUCIBLE
1.Pseudoptosis
14.COMPRESSIBLE
2.Miosis
3.Enophthalmos
C.PERCUSSION 4.Anhidrosis
-Tympanic/ Dull 4.PALPATION OF CERVICAL LYMPH NODES
D.AUSCULTATION
C.PERCUSSION
1. BOWEL SOUND OVER THE LUMP
D.AUSCULTATION
-Heard/Not heard
2. PULSATILE SWELLING E.MEASUREMENT OF NECK CIRC-

UMFERENCE
E.STATE OF THE REGIONAL
LYMPH NODES F.GENERAL EXAMINATION
1.PRIMARY TOXIC MANIFESTATION
F.MOVEMENT OF THE NEAR BY A.EYE SIGNS
JOINT
1.LID RETRACTION
2.EXOPHTHALMOS
• VON GRAEFE’S SIGN

90
• JOFF ROYS SIGN
• STELLWAG’S SIGN
B.PALPATION
• MOEBIUS SIGN
1.LOCAL TEMPERATURE & TENDERNESS
• DALRYMPTE’S SIGN
3.OPHTHALMOPLEGIA 2.SITUATION
4.CHEMOSIS OF CONJUCTIVA 3.NUMBER
4.SIZE- & SHAPE-
B.TACHYCARDIA 5.SURFACE
(Sleeping pulse rate is more confirmatory) 6.MARGIN
7.CONSISTENCY
C.TREMOR
8.FLUCTUATION
D.MOIST SKIN 9.TRANSILLUMINATION TEST
10.FIXITY TO THE BREAST TISSUE
2.SECONDARY THYROTOXICOSIS MANIFEST- 11.FIXTY TO THE UNDERLYING FASCIA &
ATION MUSCLES
12.FIXITY TO THE CHEST WALL
3.SEARCH FOR METASTASIS 13.PALPATION OF THE NIPPLE
III.Examination of lymph nodes
9.BREAST A.Palpation of axillary group of LNs
A.INSPECTION 1.Pectoral Group

2.Brachial Group
a.BREASTS PROPER 3.Subscapular Group
4.Central Group
5.Apical Group
1.Position – normal / displaced
2.Size & shape
B.Palpation of cervical LNs
3.Puckering / dimpling
b.SKIN OVER THE BREAST C.SYSTEMIC EXAMINATION

1.Liver
1.Colour & texture
2.Lungs
2.Engorged reins
3.Bone
3.Dimple; Retraction or puckering
4.Rectal
4.Peau d’ orange
5.Vaginal
5.Nodules
6.Ulceration sfungation
10.ULCER
c.NIPPLE
LOCAL EXAMINATION
1.Presence
2.Its position
3.Number
A.INSPECTION
4.Size- & Shape-
1.Size-
5.Surface
2.Shape – irregular / oval / vertically oval
3.Number
d.AREOLA 4.Position
5.Edge:–Undermined–TB/Punched out- trophiculeer/
1.Color Slopping – Traumatic or venous ulcer / Raised and
2.Size pearly white beaded – Rodent ulcer /Rolled out or
3.Surface- & Texture- everted – malignant ulcer
6.Floor
e.ARM & THORAX 7.Discharge
• Nature – serous / purulent / serosanguineous
f.AXILLA • Amount – Profuse / scanty
• Odor – sweet /foul
8.Srrounding area – normal / glossy, red & edematous
g.SUPRACLAVICULAR FOSSA 9.Condition of whole limb
h.RAISE ARMS ABOVE HEAD B.PALPATION

91
1.Tenderness – y / Antony 13. Exam. of LNs in other parts of body
2.Edge & margin- *Marked induration of the edge –
carcinoma
3.Base
K.SYSTEMIC EXAMINATION
4.Depth in mm
1.Cardiovascular symtem-NAD
5.Bleeding on touch – y / Antony
2.Respiratory system-NAD
6.Relation with the deeper structure –fixed to deep
3.Nervous system-NAD
sture / not fixed
4.Locomotor system-NAD
7.Surrounding skin
• Increased temp & tenderness
• Mobile / fixed to deep structure
• Loss of sensation / motor deficit
L.DIFFERENTIAL DIAGNOSIS
DISEASE POINTS IN FAVOUR POINTS IN AGAINST
EAXM OF LYMPH NODES-
-Enlarged/tender/soft/hard/stony hard/ fixed to M.PROVISIONAL DIAGNOSIS
neighbouring structure
N.SUMMARY
EXAM FOR VASCULAR
*Write only the positive history & finding
INSUFFICENCY-
Varicosevein/Atherosclerosis/Buerger’s disease/
Raynaud’s disease
EAXMINATION FOR NERVE

LESION
>Exam of sole
>Exam for sensory disturbance
11.LYMPHATICS
A.INSPECTION
1.1.Site
2.Number
3.Size
4.Shape
5.Extent
6.Margin
7.Surface
8.Discharge
9.Skin over the swelling
B.PALPATION
1.Temperature
2.Tenderness
3.Size
4.Shape
5.Extent
6.Surface
7.Margin
8.Consistency(Palmar aspect of three fingers)-Soft/
Elastic & rubbery/Firm,discrete & shotty/Stony hard/
Variable
9.Mobility
10. Fixity to surrounding skin-Y/Antony
11. Matting
12. Exam. of draining LNs

92
SURGERY CASES
31.Liver Abscess
1.Peptic Ulcer
2.Perforated Peptic Ulcer (Postoperative) ORTHOPAEDIC CASES

3.Carcinoma of Stomach 1. Osteomyletis–TB/Pyogenic (Important)
4.Gastric outlet obstruction (Important) 2. Osteosarcoma (Important)
5.Appendicitis 3. Giant cell tumor (Important)
6.Appendicular Lump 4. Ewing sarcoma (Rare)
7.Cholecystitis,Cholelithiasis 5. Nonunion (Important)
8.Obstructive Jaundice 6. Malunion (Important)
9.Gall Bladder lump 7. Osteochondritis (PO) (Rare)
10.Fibroadenoma (S) 8. Colles Fracture (Important)
11.Carcinoma of Breast 10.Bone Cyst(S)
12.Thyromegaly/Goitre/Hyperthyroidism 11.Congenital Talipes Equinus Varus (Important)
13.BHP 12.Prolapsed Intervertebral Disc (Rare)
14.Carcinoma of Prostate 13.Nerve Palsies-Ulnar Nerve Palsies etc. (Rare)
15.Carcinoma of Penis (Important)
16.Inguinal Hernia
16.Hydrocoele
17.Edema of Leg (Filariasis)
18.Ulcer (Important)
19.Diabetic Foot (S)
20.Sebaceous cyst
21.Burn (Post burn contracture) (Rare)
22.Cystic Hygroma (S)
23.Hard palate Carcinoma (S)
24.Burger’s Disease
25.Adamantinoma (S)
26.Fournier’s Gangrene(S) (Important)
27.Phimosis (S) (Important)
28.Paraphimosis (S) (Important)
29.Carcinoma Tongue (S) (Important)
30.Aphthous Ulcer (S) (Important)

93
• Amount
PAEDIATRICS HISTORY • Frequency
TAKING • Mode of feeding
• Weaning
• Age at weaning
A.INTRODUCTION • Nature or type of weaning
• Food intake before illness
1.NAME • Effect of disease process on the appetite & dietary
2.AGE intake
3.RELIGION
4.SEX G.DEVELOPMENTAL HISTORY
5.FROM(Locality)
6.OCCUPATION e.g a student by occupation -All motor,social and language
• Smiling(2 month)
C.HISTORY OF PRESENT ILLNESS • Head control(3 month)
• Creeping
• Crawling
B.CHIEF COMPLAINTS • Sitting with support(5 month)
• Sitting without support(6 month)
D.PAST HISTORY • Standing with support(8-9 month)
• Standing without support(10 month)
• Words or speech
• History of similar attack in the past and its frequency
• H/O infectious disease- TB/ Malaria/ Measles/ • Walking
Rubella/Pertusis/Acute respiratory infections(ARI) OR • Self feeding
URTI-Pharyngitis,Tonsilitis, Sore throat /Cough-When • Dressing
it is worse/ Ear discharge/ Acute gastrointestinal • Bladder & bowel control
infections (Diarrhoea) OR Bowel disturbance / • Speech
Exanthematous fever/Meningitis/ARV/Syphilis
• H/O Thalassemia/Sickle cell anemia/Other Hemoglobi- >Typical description-No delayed milestones of
nopathies development.
• H/O other serious or significant disease in the past
• H/O Seizure
• H?O of squatting/Cyanotic spells
A.KEY MILESTONES OF DEVELOPMENT-GROSS MOTOR
• H/O Taking any drug
AGE MILESTONES
E.BIRTH HISTORY(DELIVERY HISTORY) 3 Months Neck holding (No head
lag)
• Nature of delivery-Normal Vaginal/Forceps Delivery/ 5 Months Sitting with support
Caesarean section (4-5month)
• Place of delivery-Home/Hospital
>Normal vaginal home delivery. 8 Months Sitting without support
(7-8 month)
• Cried just after birth-Yes/No
• 9 Months Standing with support
F.NUTRITIONAL HISTORY 10 Months Walking with support
11 Months Crawling (Creeping)
A.
• When was the baby fed
12 Months Standing without
• How was the baby fed(Weaning) support
• Source of milk 13 Months Walking without support
• Vitamin drop
• Was the weight gain satisfactory 18 Months Running
• General dietary intake of child 24 Months Walking upstairs
B. 36 Months Riding tricycle
• Received breast feeding or not
• Frequency
• Type of schedule(On time or on demand)
B.KEY MILESTONES OF DEVELOPMENT-LANGUAGE
• Duration
• Reasons for discontinuance of breast feeding AGE MILESTONES
• If topfed 1 Months Turns head to sound
• Mode of top feeding 3 Months Cooing
• Age at starting 6 Months Monosyllables(Ma,Ba,Da)
• Nature formula
• Dilution of formula feeds 9 Months Bisyllables(Mama,Baba)
94
12 Months Two words with meaning • Completely immunized-BCG/OPV/DPT/Measles/DT/
18 Months Ten words with meaning TT
24 Months Simple sentence • Fully immunized-BCG/OPV/DPT/Measles/DT/TT
36 Months Telling a story • Partially immunized-BCG/OPV/DPT/Measles/DT/TT
• Unimmunized
• Child is completely immunized-It means child has
taken first DPT booster at the age of one and half
C.KEY MILESTONES OF DEVELOPMENT-PERSONAL year.See the card if present.
SOCIAL • Presence of BCG scar
• Timing of various primary & booster immunization
AGE MILESTONES received so far
8 Weeks Social smile (6-8Week) J.SIBLING HISTORY

3 Months Recognising mother • Any illness in siblings-Allergy Or Chronic illlness/They
6 Months Smiles at mirror image are healthy
9 Months Waves bye-bye • Number of siblings & their age & sex
12 Months Plays a simple ball game a.Brothers-1.____Year, 2.____Year, 3.____Year
36 Months Knows gender b.Sisters-1.____Year, 2.____Year, 3.____Year
D.KEY MILESTONES OF DEVELOPMENT-FINE MOTOR K.FAMILY HISTORY

AGE MILESTONES • Any still birth/Miscarriage/Childhood death
4 Months Grasps a rattle or rings when placed in • H/O any background of inherited disease
hand • Sickle cell history
5 Months Reaches out to an object & holds it with • H/O Consanguinity of marriage-Thalassemia/
both the hands(Intentional reaching with Hemophilia/G-6-PD deficiency/Pseudohypertrophic
BIDEXTROUS grasp) muscular dystrophy
7 Months Holding objects with crude grasp from • Contact with possible infection(Any illness in parents
palm(PALMAR grasp) or any near relatives)-Viral fever/TB/ Leprosy/
Childhood infection/Infectious hepatitis/ Typhoid
9Months Holding small object like a fever/Scabies/Pyoderma
pellet between index finger • H/O similar ailment in family member
& the thumb(PINCER grasp) • Father’s age & occupation
• Mother’s age & occupation
D.TARGET MILESTONES L.SOCIAL HISTORY

>The upper age limits for achievement of some of the
• Family type-Nuclear/Joint/Extended
Target milestones are given below-
• Income
" Lack of social smile by 2 months.
• Housing
" Absence of stable head control by 4 months.
" Inability to recognize mother by 6 months.
" Inability to sit when pulled to sit by 6 months & lack E.PERSONAL HISTORY
of independent sitting without by 8 months.
" Lack of creeping by 9 months. >Usually taken in children above 8 years.
" Inability to stand without support by 1 year. " Occupation
" Inability to walk without support by 18 months. " Socio-economicstatus-Poor/Average/High
" Absence of syllabic babbling by the age of 1 year income status
and failure to make meaningful sentences by the " Dietary habit-
age if 3 years. a.Regular/Irregular/Fasting/Avg.Indian diet
" Lack of pincer grasp by the age of 1 year. b.Veg/Non-veg
" Inability to play interactive games by the age of 1 " Addiction-1.Alcohol-a.Amount- b.Duration
year. 2.Smoking- a.No.s- b.Duration
3.Tobacco in any form
>The recommended corrected ages for undertaking " Bowel habit-Normal/Altered
developmental assessment are 4 months, 8 months, " Bladder habit-Normal/Altered
12 months and then every 6 months until 3 years of " Sleeping habit-At first > 80% or not
age.
I.IMMUNISATION HISTORY G.TREATMENT HISTORY
• Child is immunized M.PHYSICAL EXAMINATION

• As per the age-BCG/OPV/DPT/Measles/DT/TT

95
a.ANTHROPOMETRY >The chest circumference is measured by encircling the
tape at the level of nipples.
! WEIGHT >32 cm
> WEECH’S FORMULA FOR AVERAGE WEIGHT IN KG ! MID UPPER ARM (LEFT) CIRCUMFERENCE (ONLY
• For 3-12 months=(Age in months+9)/2 FOR CHILDREN BETWEEN 1-5 YEARS).
• For 1-6 years=(Age in years into 2)+8
• Foe 7-12 years={(Age in years into 7) – 5}/2
> It is not taken in less than 1 year of age.
>METHOD OF MEASUREMENT OF MID UPPER ARM (LEFT)
>Rate of weight increase CIRCUMFERENCE-It is measured with a fibreglass or
steel tape at the midpoint between acromion &
! HEIGHT(or RECUMBENT LENGTH WITH THE HELP olecranon. The tailor’s tape is not accurate & should not
OF AN INFANTO METER IF CHILD IS LESS THAN be used.
2 YEAR) >During 1-5 years of age mid upper arm circumference
>Formula for approximate average height

remains reasonably static between 15-17 among
" At birth=50 cm healthy children. Value exceeding 13.5 cm is sign of
" At 2 year=75 cm satisfactory nutitional status, between 12.5-
" 2-12 year=Age in year into 6 + 77
13.5 cm indicates moderate malnutrition & less
>Rate of height increase than 12.5 cm indicates severe malnutrition.
>Height can be measured in children over the age of 2 ! SPAN

years against a wall-mounted gauge.Upto 2 years of
! US/LS RATIO (Upper segment,Lower segment)
age,recumbent length is measured with the help of an
INFANTOMETER.
! DEGREE OF MALNUTRITION
>METHOD OF MEASUREMENT OF HEIGHT-The child is
asked to stand against a wall on a flat floor with feet
b.VITAL SIGNS
bare & parallel to eachother & with the heels, buttocks,
shoulders and occiput touching the wall.The head should c.GENERAL EXAMINATION
be held erect with the eyes aligned horizontally and ears
vertically without any tilt.Then with the help of a 1.He is conscious & cooperative/Uncooperative
wooden spatula or plastic ruler,the topmost point of the
vertex is identified on the wall. 2.BODY BUILT
>Length is measured by infantometer while height is -Average body built/Fat/ Thin/ Cachectic/
measured by stadiometer. Length of a newborn baby is Emaciated/Tall/Short
50 cm.
>Exected height upto 12 year in cm-Age in years into 6 3.NUTRITION
plus 77.
-Moderate/Undernutrition/Obese/Dehydration-Mild/
! HEAD CIRCUMFERENCE Moderate/Severe (P 35 of MS)
*Patient is moderately nourished.
>In infants under the age of 2 years,the head >Look for clinical evidence of marasmus, marasmic
circumference should be measured.Take head kwashiorkor and kwashiorkor.
circumference in all infants.
5.FACIES
>METHOD OF MEASUREMENT OF HEAD CIRCUMFERENCE-
The tape should encircle over the most prominent part -Thalassemic/Malar flush/ Toxic(Dehydrated)/
of occiput,over the supraorbital ridges of frontal bone & Ill/Anxious
above the mastoid process.
>At birth,HC is 35 cm.During first 6 month,the HC 4.PALLOR
increases by 6 cm & then in second 6 month HC
increases by another 6 cm. -Mild/Moderate/Severe
>Hydrocephalus should be suspected when the rate of
growth of the head is greater than the normal for the 5.ICTERUS
age,sex & size of the infant.
>Head circumference Vs Abdominal circumference- -Mild/Moderate/Severe
Meherban singh
6.CYANOSIS
! CHEST CIRCUMFERENCE -Peripheral/Central
96
>Differential cyanosis may occur due to right-to-left c.PRESACRAL-press over sacrum in left or right
shunt through patent ductus arteriosus due to severe lateral position in prolonged bed ridden patient.
pulmonary arterial hypertension.
>In newborn babies & infants,sacral edema & puffiness
7.ENGORGEMENT OF NECK VEINS may be seen while pedal edema is rare.
>In case of bilateral leg edema, ask the Pt. on which leg
>JVP is difficult to evaluate in infants due to short & fat it appeared first.
neck.
>In infants with congestive heart failure,scalp veins may 13.CONDITION OF SKIN
become prominent & engorged.
Hepatojugular reflux is a sign of right ventricular -Scratch marks/Loss of skin turgidity &
compromise. elasticity/Subcutaneous nodules/Erythema
marginatum/Purpura/ Ecchymoses / Spider
8.LYMPH NODE ENLARGEMENT angioma/Palmar erythema /Xanthoma Colour/Txture/
Skin rash/ Nodules/ /Pigmentation/Pyoderma/ Eczema/
-Cervical/Axillary/Inguinal/Popliteal/Epitrochlear/Para- Neuroectodermal dysplasia/Nevi
aortic
• Site >Tell above when present.Otherwise,do not tell.Scratch
• Temperature marks are found in case of obstructive jaundice & loss of
• Tenderness skin turgidity occurs in dehydration.
• Number >FEATURES OF MARASMUS- Wasted extremities,poor
• Size muscle mass,loss of subcutaneous fat(skin hangs in
• Shape folds over buttocks & thighs) & visible bony
• Extent prominences.
• Surface >FEATURES OF KWASHIORKOR- Apathy, growth
• Margin-Discrete/Confluent retardation, generalized edema,sparse hair &
• Consistency(Palmar aspect of three fingers)-Soft/ crazy-pavement dermatosis over legs.
Elastic & rubbery/Firm, discrete & shotty/Stony hard
/ Variable/Hard/Discrete 14.CONDITION OF
• Mobility-Movable/Fixed
• Fixity to surrounding skin-Yes/No a.Hair-Color/Texture/Brittleness/DistributionEyebrows/
• Matting-Present/Absent Eyelashes/Hirsutism
• Examination of draining LNs
• Examination of LNs in other parts of body b.Nail- Clubbing/Flattening or koilinychialWhite nail or
Leuconychia/Splinter hemorrhage/Transluscent bands
9.THYROID SWELLING
>Tell when present.Otherwise, do not tell.In SLE,there is
a.Size- b.Shape- c.Thrill-Preent/Absent loss of hair i.e alopecia is found.In hypoproteinemia(or
10.CLUBBING-Drum stick type/Parrot beak type anemia-hypoproteinemia, hair becomes
a.Onychodermal angulation-Present/Lost 15.TONGUE-Glossitis/Papillary atrophy

b.Fluctuation test-Positive/Negative
>Marked clubbing is seen in children with cyanotic heart 16.ANGLE OF MOUTH-Angular stomatitis/Cheliosis
disease.
17.BITOT’S SPOT-Present/Absent
11.KOILONYCHIA
18.VITALS
12.EDEMA OF DEPENDENT PARTS
A.PULSE
-Bilateral/Unilateral
a.Rate-____ Beats/min(Radial artery)
EXAMINATION FOR PARIETAL EDEMA
b.Rhythm (Radial artery)-Spacing of successive beats in
>Observe carefully for puffy face, puffy lower lids & time
scrotal edema.Edema may be seen over sternum & >Regular
forehead in a case of anasarca. >Irregular
>Sinus arrhythmia in which pulse rate becomes first
a.PRETIBIAL-press over medial surface of the lower during inspiration & slow during expiration is common &
end of the tibia physiological in children.
b.PEDAL-press over dorsum of foot. c.Volume [Carotid artery(Right)]-Good/High/Low

>Good Volume(Tell in a normal case)

97
>High Volume (Pulse pressure > 60 mm of Hg) >Axillary temperature is taken or preffered in infants &
>Low Volume (Pulse pressure < 30 mm of Hg) preschool children (< 6 year). Axillary temperature is
0.5 C lower than the oral temperature while the rectal &
d.Character[Carotid artery(Right)]–Normal/Bounding/ the eardrum temperature is 0.5 C higher than the oral
Collapsing or Water hammer Pulse/Plsus alternans/ temperature. Rectal temperature may be recorded in
Pulsus bigeminus/Pulsus paradoxus/ Bisferiense pulse critically sick children but should be avoided as a routine
procedure.
e.Symmetry >It should be remembered that many normal children
have diurnal variations in their body temperature, being
f.Radio–Femoral Delay-One should palpate the radial & lowest in the early morning & highest in the evening
femoral artery simultaneously. around 4 P.M.
>Mild elevations of temperature (Oral temperature up to
g.Condition of arterial wall-Arterial wall is just 37.7 C or 99.9 F) in some children especially during the
palpable(in normal case)/Thickened afternoons in summer months is not indicative of any
disease process.
h.All Peripheral Pulses-Palpable & equally felt on both
sides Age Temperature Pulse Respirati BP(mm of
Rate on Rate Hg)
B.BLOOD PRESSURE Newborn 36-37 140 40 65/45
1 Year 36.5-37.5 110 30 70/50
a.________mm Hg 3 year 100
4 Year 85/60
b.METHOD OF MEASURING BLOOD PRESSURE IN 5 Year 37+/- 0.2 20
LOWER LIMB 8 Year 90 95/65
10 Year 37+/- 0.2 18 100/75
>Measure blood pressure in both the upper & lower 11Year 37+/- 0.2 80 18 110/80
limbs on both the sides.Ideal cuff size-The cuff
should cover two-third of the upper arm. The point
at which the Korotokoff sounds become low pitched & N.SYSTEMIC EXAMINATION
muffled is regarded as the best index of diastolic blood
pressure in children whereas in adult disappearance of >The adolescent girl must be examined in the presence
sound is regarded as a better criterion. of a nurse or female attendant.
>In infants & babies it is difficult ro measure blood >Respiratory & cardiovascular system to be examined in
pressure by conventional method & in them blood all pediatric cases.
pressure is measured by flush method. FLUSH
METHOD-Cuff is wrapped around the upper arm,limb is
raised vertically & held above the head till palm 1.EXAMINATION OF CVS
becomes pale.The pressure in the cuff is raised beyond
th expected systolic blood pressure while maintaining >Respiratory & cardiovascular system to be examined in
the arm in vertical position.The arm is then brought all pediatric cases.
down to the side of the bed & the cuff is gradually >Pulse is rapid & difficult to feel among infants due to
deflated.The point at which the palm becomes flushed is decreased vagal tone.Sinus arrthymia is common.
indicative of systolic blood pressure in the infant.The >JVP is difficult to evaluate in infants due to short & fat
diastolic blood pressure can no t be recorded by this
neck.
method.In newborn babies & young infants,it is more
>It is preferable to auscultate the heart of an infant first
reliable to use noninvasive Doppler system to record the
blood pressure. which should be followed by inspection, palpation,
percussion & recording of blood pressure.
>In all CVS cases, measure BP in all four limbs.
>Precordial bulging may occur as a sign of long standing
cardiac enlargement due to soft rib cage.
C.RESPIRATORY RATE
>In children, apex beat is located in the 4th ICS at or
slightly outside the MCL.
a.____/min-Tachypnea/Bradypnea
>In children, splitting of second heart sound is common.
b.Type-Abdominothoracic/Thoracoabdominal/ P2 is louder than A2 in infants uptp 6 months.Heart
Exclusively abdominal sounds are louder & better audible due to the thin chest.
>Functional systolic murmurs & venous hum are
>The breathing is mostly abdominal or abdomino- common in children.
thoracic in infants & it becomes predominantly thoracic >Sinus arrhythmia in which pulse rate becomes first
after the age 5 years. during inspiration & slow during expiration is common &
physiological in children.
D.TEMPERATURE >Hepatomegaly is the most reliable sign of CHF in
infants.
: _____F

98
>Signs of CHF-Dyspnea (Breathlessness),tachycardia. b.FORCEFUL & WELL SUSTAINED (HEAVING)
raised JVP, enlarged tender liver,cardiomegaly & basal
crackles. c.FORCEFUL & ILLSUSTAINED (HYPERDYNAMIC)
>Pulse is rapid & difficult to feel among infants due to
decreased vagal tone.Sinus arrthymia is common. d.TAPPING
>The presence of a continiuos murmur in a cyanotic
patient is a recognized feature of patenr ductus B.PALPABLE FIRST HEART SOUND (S1)-P/ A
arteriosus, rupture of sinus of Valsalva fistula into the
right atrim or right ventricle. C.PULSATION-Present/Absent
I.INSPECTION(OF PRECORDIUM) D.THRILL
1.SHAPE & SYMMETRY OF THE CHEST 1.SYSTOLIC
a.Bilaterally symmetrical 2.DIASTOLIC
b.Precordial Bulging/Bulging intercostals spaces / 3.SYSTOLO-DIASTOLIC(CONTINUOUS)

Kyphosis/Scoliosis
>Precordial bulging may occur as a sign of long standing 2.PULMONARY AREA
cardiac enlargement due to soft rib cage.
>Bulging intercostals spaces-Pericardial effusion A.PALPABLE P2
3.PROMINENT VEINS OVER THE CHEST WALL B.PULSATION
-Absent/Present-Pulsatile/Nonpulsatile
C.THRILL
4.SCAR MARK/SINUS
3.AORTIC AREA
2.PULSATION
A.PALPABLE A2
a.No visible pulsation
b.Apical pulsation
B.PULSATION
c.Visible pulsation in-Parasternal area/ Pulmonary
area/ Epigastrium/Suprasternal area/ Carotid
pulsation/ Locomotor brachialis C.THRILL
>Precordial pulsation-Left-to-right shunt, aortic 4.TRICUSPID AREA

regurgitation,mitral regurgitation
A.PARASTERNAL HEAVE
II.PALPATION
-Absent/Present-GradeI/II/III
>The apex beat is best palpated with the child sitting &
B.PULSATION
leaning forward.
>IN pre-school children,the apex beat is locared in the
C.THRILL
4th ICS just lateral to the MCL.
5.THRILL OVER CAROTID ARTERIES
1.MITRAL AREA
CAROTID SHUDDER
A.APEX BEAT
1.LOCATION-4th ICS at or slightly outside the MCL /5th

6.FEEL FOR THE
ICS ½ inch medial to MCL or displaced-
inside or outside the MCL/___th ICS inside or outside A.EPIGASTRIC PULSATION
the MCL
>In children,apex beat is located in the 4th ICS at or B.SUPRASTERNAL PULSATION
slightly outside the MCL.Subsequently,the apex beat is
located in the 5th ICS inside or over the MCL
III.PERCUSSION
2.CHARACTER
(Done in pericardial effusion, otherwise it is not done.)
a.NORMAL
a.Left 2nd ICS-Resonant/Dull

99
rd
b.Left 3 ICS- Resonant/Dull B.QUALITY=CHARACTER
>Normally, the left 2nd ICS is resonant & cardiac -Soft/Softblowing/Rough/Loud & rough
dullness does not extend beyond the apex.
>Second ICS is obliterated (i.e dull on percussion) in C.LOUDNESS GRADE
pericardial effusion etc.
>Normally, the Lt. 3rd ICS is dull on percussion. -I/VI,II/VI,III/VI, IV/VI, V/VI,VI/VI
IV.AUSCULTATION c.GALLOP RHYTHM
>Mitral stenosis-Left lateral position with the bell of the -Present/Absent

stethoscope.Aortic regurgitation-Child sitting, leaning
forward & during expiration with the diaphragm of the B.PULMONARY AREA
stethoscope. Tricuspid regurgitation-End of deep respi-
ration. 1.HEART SOUND
>Murmurs originating from the right side of the heart
increase in the intensity during inspiration owing to D.RADIATION TO
increase in the stroke output of thr right
ventricle.Conversely,murmurs arising from the left side 2.MURMUR
of the heart is accentuated during expiration.
3.ADDED SOUND
A.MITRAL AREA
C.AORTIC AREA
1.HEART SOUND
>First heart sound(S1)-Heard with the diaphragm 1.HEART SOUND
a.Intensity-Normally heard/Loud & snapping(in
MS)/Distant(in Pericardial effusion) >In children,splitting of second heart sound is
b.Rhythm common.P2 is louder than A2 in infants uptp 6
months.Heart sounds are louder & better audible due to
2.MURMUR the thin chest.
>The presence of a continiuos murmur in a cyanotic
2.MURMUR
patient is a recognized feature of patenr ductus
arteriosus,rupture of sinus of Valsalva fistula into the
3.ADDED SOUND
right atrim or right ventricle.
A.TIMING D.TRICUSPID AREA
1.SYSTOLIC E.POSITION
a.EJECTION SYSTOLIC(=MID-SYSTOLIC)- F.HEARD BEST WITH
3.ADDED SOUND -Bell/Diaphragm of the stethoscope
a.OPENING SNAP-Present/Absent G.HEARD BEST IN-Full expiration/Full inspiration
b.EJECTION CLICK-Present/Absent 1.HEART SOUND
b.PANSYSTOLIC(=HOLOSYSTOLIC) 2.MURMUR
c.LATE-SYSTOLIC- 3.ADDED SOUND
2.DIASTOLIC E.LEFT 3rd& 4th PARASTERNALREGION

a.EARLY DIASTOLIC >NEOAORTIC AREA
rd
NEOAORTIC AREA-Lt. 3 ICS
b.MID-DIASTOLIC
c.PRESYSTOLIC(=LATE-DIASTOLIC)- F.CAROTID BRUIT

3.CONTINUOUS(=SYSTOLO-DIASTOLIC)- -Heard/Not heard

100
G.PERICARDIAL FRICTION RUB 2.MOVEMENTS OF THE CHEST WALL WITH
RESPIRATION
-Present/Absent
• Both the sides of the chest move simultaneously &
symmetrically
F.OTHER • Restriction of movement in any part
1.CAROTID BRUIT 3.FULLNESS/DEPRESSION OF CHEST

2.QUINCKE’S SIGN
3.COLLAPSING PULSE a.Localised-Right/Left
4.LOCOMOTOR BRACHIALIS b.Generalised-Right/Left
5.CORRIGAN’S PULSE
6.DE MUSSET’S SIGN—AUSCULTATION 4.PROMINENT VEINS OVER THE CHEST WALL
7.PISTOL SHOT SOUND – AUSCULTATION Absent/Present-Pulsatile/Nonpulsatile
8.DUROZIEZ’SMURMURS—AUSCULTATION
9.HILL’S SIGN– B.P 5.POSITION OF TRACHEA
-Central/Shifted to right / Shifted to left

2.RESPIRATORY SYSTEM >The trachea is examined in the child in sitting position
EXAMINATION with slight flexion of the neck.
6.LOCATION OF APICAL IMPULSE

>The trachea is examined in the child in sitting position
with slight flexion of the neck. -5th ICS 1.5cm medial to MCL/Displaced-Inside or
>In children,the normal breath sounds are puerile or outside the MCL
harsh veicular with slightly prolonged expiration
(Bronchovesicular). 6.DROOPING OF SHOULDER
>The breathing is mostly abdominal or abdomino-
thoracic in infants & it becomes predominantly thoracic -Present/Absent
after the age 5 years.
>The breathing is rapid & abdominothoracic among 7.CROWDING OF RIBS
infant.Normal rhythm of breathing is characterized by
Inspiration#Expiration#Pause.Revesed respiratory -Present/Absent
rhythm i.e Expiratory grunt#Inspiration#Pause is seen
in children with acute lower respiratory tract infection 8.WIDENING OF INTERCOSTAL SPACES
like pneumonia.
>Intercostal &suprasternal recessions are common due - Present/Absent
to soft ribs.
>The chest is more resonant in children as compared to 9.SKIN
adults.Percussion may be impaired over the manubrium
sterni due to enlarged thymus. -Puncture mark/Scar mark/Discharging sinus
>Due to thin chest wall the normal vesicular breath
sound is more loud as compared to adults. 10.RESPIRATORY MOVEMENT
>Due to small thorax,the adventitious sounds from one
side may be conducted to the opposite side. a.Rhythm
1.Regular
>In children,narrow air passages predisposes to
2.Irregularly irregular
frequent occurrence of stridor,rhonchi & atelectasis.
3.Regularly irregular=Cheyne-Stokes respiration
4.Miscellaneous-Kussmaul’s breathing/Stertorous
I.INSPECTION breathing
b.Type-Abdominothoracic/Thoracoabdominal/
1.SHAPE & SYMMETRY OF THE CHEST Exclusively abdominal/Exclusively thoracic/
Paradoxical respiration
a.Bilaterally symmetrical
b.Kyphosis/Scoliosis/Precordial bulging/Bulging c.Depth-Shallow/Deep
intercostals spaces/ Flattening of chest wall
d.Indrawing of
>Note the distance of medial borders of scapulae from • Intercostal spaces(Intercostal suction)-Present/Absent
midline on the both sides which is useful to assess any • Subcostal spaces-Present/Absent
asymmetry of the chest. • Suprasternal space-Present/Absent
>There is bulging of intercostals spaces in pleural
e.Accessory muscles of respiration-Used/Not used
effusion or empyema.
(Sternomastoid,scalenii & trapezii)

101
f.Apical impulse-5th ICS ½ inch medial toMCL/
Displaced-Inside or outside the MCL.
IV.AUSCULTATION
II.PALPATION 1.BREATH SOUNDS
1.POSITION OF TRACHEA >In children, the normal breath sounds are puerile or
harsh veicular with slightly prolonged expiration
- Central/Shifted to right/ Shifted to left (Bronchovesicular).
3.MOVEMENTS OF CHEST a.INTENSITY-Normal/Diminished/Increased

-Bilaterally symmetrical/Restricted in-Rt side/Lt side
b.QUALITY-
2.LOCATION OF APEX BEAT • VESICULAR
• BRONCHIAL-Tubular/Cavernous/Amphoric
th
-5 ICS ½ inch medial to MCL/Displaced-Inside or •
outside the MCL 2.VOCAL RESONANCE
4.EXPANSION OF CHEST A.QUANTITATIVE CHANGE
a.Normal
5.VOCAL FREMITUS
b.Decreased/Much diminished/Entirely abolished
-Normal/Increased/Reduced
c.Increased
6.TENDERNESS OF RIBS
1.BRONCHOPHONY
-Absent/ Present-Right/Left
5.SCRATCH TEST (OR SCRATCH SIGN)
7.CROWDING OF RIBS
-Absent/ Present-Right/Left B.QUALITATIVE CHANGE

8.WIDENING OF INTERCOSTAL SPACES
a.AEGOPHONY
- Absent/Present-Right/Left 3.ADDED SOUND
III.PERCUSSION -Wheezes(Rhonchi)/Crackles(Rales/Crepitation)-
Fine,Medium or Coarse/ Stridor/Pleural friction rub
1.PERCUSSION NOTE
>Fine crepitations are found in bronchopneumonia &
-Resonant /Hyperresonant/ Impared/Dull/Stony dull CHF.
2.CARDIAC DULLNESS 4.SUCCUSSION SPLASH
-Present in left parasternal region over 3rd to 5th -Present/Absent

space/Lost
2.WHISPERING PETORILOQUY
3.HEPATIC DULLNESS
-Starts from 5th ICS in Rt. MCL/ Displaced upwards 3.GASTROINTESTINAL

4.TIDAL PERCUSSION
SYSTEM EXAMINATION
-Normal/Increased/Reduced/Absent >The protuberant (Potbelly) contour of the abdomen is
normal in infants & should not be considered as an
5.COIN PERCUSSION evidence of liver disease.
>Divarication of recti & umbilical hernia are common in
6.TRAUBE’S SPACE PERCUSSION children.
>Pre-school chikdren are best examined in a standing
7.ELICITATION OF HORIZONTAL FLUID LEVEL position.During palpation,watch the child for any change
in facial expression,wincing or screwing of eyes or
8.SHIFTING DULLNESS forehead as an evidence of tenderness.It is unnecessary
& unreliable to ask the child wheather it hurts.
-Present/Absent

102
>Palpation of abdomen in infants is best achieved during -Scar mark/Scratch mark/ Yellow discolouration/
feeding. Ulcer/Ecchymosis/Scaly/Puncture mark/Shiny
>The liver is normally palpable upto 2 cm below the
right costal margin throughout the childhood. 6.ANY LOCALISED SWELLING
>Spleenic margin is characterized by a notch.Spleen tip
may be normally palpable during first 3 months of life. 7.MOVEMENT OF THE ABDOMEN
>In children,tell that liver is palpable x cm below the
right costal margin.Do not tell liver is enlarged. -Respiratory movement/ Peristalsis/ Pulsation
(epigastrium)
I.INSPECTION
8.HERNIAL SITES
A.UPPER GIT -Inguinal/Femoral/Umbilical/Epigastric/Incisional
1.THE LIPS
>Hernial orifices are intact. You must mention about the
2.THE ANGLE OF MOUTH condition of the hernial orifices.
-Normal/Angular stomatitis II.PALPATION

3.THE TEETH A.SUPERFICIAL PALPATION
-Chewing surfaces are normal/Caries 1.TENDERNESS
4.THE GUMS
-Absent/Present in_______area or at Mc Burney’s
point/ Galldder point/Epigastrium/ Renalangle
-No bleeding/Bleeding/Hypertrophy
2.CONSISTENCY (FEEL)
5.THE TONGUE
-Normal elastic/Tense OR Rigid
a.Size-Normal/Atrophy/Hypertrophy
b.Surface-Smooth/Bald
3.DIRECTION OF BLOOD FLOW IN PROMINENT
c.Color-Pink/Pale VEINS
d.Ulcer-Present/Absent
a.AROUND UMBILICUS-Towards/Away from umbilicus
6.THE ORAL CAVITY-Moderate in hygiene
b.ABOUT MID-AXILLARY LINE-From above downwards/
From down upwards
B.ABDOMEN
4.FLUID THRILL
1.SHAPE OF THE ABDOMEN
-Present/Absent
-Scaphoid/Protuberant OR Distended
>The protuberant(Potbelly) contour of the abdomen is 5.PULSATION
normal in infants & should not be considered as an
evidence of liver disease. -Transmitted/Expansile
2.VENOUS PROMINENCE 6.PARIETAL EDEMA
a.Around umbilicus-Present/Absent -Present/Absent

b.About mid-axillary line-Present/Absent
7.GIRTH OF THE ABDOMEN(at umbilicus with tape in
3.UMBILICUS cm)
a.Location-Midway between xiphisternum & B.DEEP PALPATION

symphisis pubis/Displaced up OR down
b.Inverted/Everted 1.LIVER
4.FLANKS • Palpable___cm below the costal margin

at Rt. mid-clavicular line(Measurement taken during
-Full/Empty normal expiration).
>The liver is normally palpable upto 2 cm below the
5.CONDITION OF SKIN right costal margin throughout the childhood.
• Tenderness-Tender/Nontender
103
• Margin-Sharp(palm leaf)/Rounded/Irregular 14 year 6.8 cm 2.0 cm
>The normal liver is soft in consistency & has round
margin. >Liver dullness is normally present between 6th rib to
• Upper border of liver dullness-Starts from Rt.___ costal margin(which is obliterated if there is free gas in
ICS at MCL the peritoneal cavity.
• Consistency-Soft/Firm/Hard
• Surface-Smooth/Granular/Nodular/ Irregular
• Moves with respiration 3.SHIFTING DULLNESS
• Left lobe-Enlarged/Not enlarged
4.PUDDLE SIGN
2.SPLEEN
-Positive/Negative
a.Tenderness-Tender/Nontender
b.Palpable___cm below the costal margin in Rt.
mid-clavicular line IV.AUSCULTATION
c.Consistency-Soft/Firm/Hard
d.Notch-Felt/Not felt 1.BOWEL SOUND-Epigastrium/Right Iliac fossa
>Spleenic margin is characterized by a notch.Spleen tip
may be normally palpable during first 3 months of life. 2.VENOUS HUM
e.Surface-Smooth
f.Moves with respiration 3.SPLENIC RUB-Sickle cell anemia
g.Inability to insinuate the finger between the
mass & costal margin >Friction rub over the enlarged liver & spleen is
suggestive of perihepatitis & perisplenitis (Sickle cell
3.KIDNEY-Ballotable/Not ballotable anemia, Abscess, Leukemic infiltrate)
4.ANY OTHER MASS

4.RENAL ARTERY BRUIT
a.Site
b.Size
c.Surface
V.PER-RECTAL EXAMINATION
d.Skin over it
e.Edge >Ask for gloves for doing per-rectal examination.
f.Extension
5.HERNIA & EXTERNAL GENITALIA
- Effect of coughing
- All hernial sites are intact.
6.TESTIS(both sides)
III.PERCUSSION
1.GENERAL NOTE OF THE ABDOMEN
-Dull/Tympanic
2.LIVER DULLNESS/LIVER SPAN
LIVER SPAN IN NORMAL CHILDREN (Mean+/-SEM in cm)
AGE LIVER SPAN IN cm SEM

6 month 2.4 cm 2.3 cm
1 year 2.8 cm 2.0 cm
10 year 6.1 cm 1.6 cm
12 year 6.5 cm 1.8 cm

104
PAEDIATRIC CASES
1. Nephrotic syndrome (AGN) (Important)
2. Nephritic syndrome (Important)
3. Pneumonia (Important)
4. Congenital heart desease ( VSD, TOF, ASD)

(Important)
5. Congenital Heart Disease with VSD with

Pneumonia.
6. Empyema Thoracis (Rare)
7. Malaria/Cerebral malaria
8. Rheumatic heart disease (Isolated or with MS/

MR/AR)
9. Meningitis– TB/Pyogenic
10. Thalassemia (Important)
11. Sickle Cell Anemia (Important)
12. Leukaemia (ALL or AML) (Important)
13. Viral Hepatitis (Important)
14. Pleural Effusion
15. Portal Hypertension (Important)
16. Hydropneumothorax (Rare)

105
GYNECOLOGY HISTORY TAKING 1.PARA
Number of times the lady has undergone parturition

(including vaginal delivery as well as delivery by
A.INTRODUCTION caesarean section) beyond the period of viability i.e
1.NAME beyond the 28th week of pregnancy that means
2.AGE abortions are not included under para. In other
3.RELIGION words,parity denotes a state of previous pregnancy
4.SEX beyond the period of viability.
5.FROM(Locality)
6.OCCUPATION 2.ABORTION
B.CHIEF COMPLAINTS -Spontaneous/MTP

1.PROGRESSIVE SWELLING OF THE ABDOMEN
2.MENSTRUAL IRREGULARITY >Mention the duration of pregnancy at which abortion
3.SOMETHING COMING OUT OF THE VAGINA occurred.
4.URINARY SYMPTOMS >Expulsion of conception before 28th week of
5.PELVIC PAIN & PRESSURE SYMPTOMS pregnancy.
6.INFERTILITY & RELATED SEXUAL PROBLEMS
7.WHITE DISCHARGE 3.LIVING CHILDREN
8.A COMBINATION OF ABOVE PROBLEMS
a.Number of living children-L1/L2/L3/L4/L5/L6/L7/L8
-Twins are taken as L2 but G1 i.e gravida one.
C.HISTORY OF PRESENT ILLNESS b.Boys-
c.Girls-
D.MENSTRUAL HISTORY d.Health status of each child/baby-They are healthy
e.Immunisation status of each child/baby-They are
I.PRESENT CYCLE adequately immunised
f.Last Child Birth (LCB)/ Last issue-
a.Age of menarche
b.LMP (First day of the last normal menstrual period) Typical description-She is blessed with 4 children & all
c.Duration of bleeding are healthy.
d.Length of the cycle (It is the interval from the first
day of one period to the onset of the next period) Typical description of obstetric history-She is para
e.Regularity of the cycle (Rhythm)-Regular/Irregular 2 & had no abortion.She has 2 children,1 boy of 5 year
f.Associated clot & 1 girl of 2 year,all are born by normal vaginal delivery
g.Associated pain at home(or hospital),all are healthy & adequately
immunized.The last child birth was on 24th
II.PREVIOUS CYCLES March,2006.The expected date of delivery is on 21st
April,2008.
a.Duration of bleeding (Describe about each living children-Age, delivery-
b.Length of the cycle (It is the interval from the first Normal vaginal/CS,Now healthy or not)
c.Regularity of the cycle (Rhythm)-Regular/Irregular F.HISTORY OF PAST ILLNESS
d.Associated clot (MEDICAL, SURGICAL & GYNAECOLOGICAL)
e.Associated pain
1.History of similar attack in Past
*Mention about past menstrual history only if previous 2.ANY GYNECOLOGICAL OPERATIONS
cycles are irregular.Otherwise tell-Previous cycles are 3.ANY SURGICAL OPERATIONS
regular. 4.ANY CONTRACEPTIVE MEASURES USED
5.No history suggestive of TB/HTN/Diabetes/RHD/
*Typical description-Menstrual period is 2-3 days in a IHD/Jaundice/H/O contact with persons suffering from
cycle of 28-30 days duration, regular, not associated TB or any contagious disease(or Pt. is not a diabetic,not
with pain & clot. OR Menstrual period is 2-3 days in a a hypertensive etc.)
cycle of 28-30 days duration, regular & with average 6.Prolonged illness/Serious illness in the past
blood flow. (Average blood flow indicates it is not
associated with clot) G.PERSONAL HISTORY
*Clot in menstrual flow indicates heavy bleeding.It can 1.Occupation
also be determined by number of pads used. 2.Socioeconomicstatus-Poor/Average/High income
status
3.Marital status-Married/Unmarried/Widow/ Divorced/
E.OBSTETRIC HISTORY Separated
4.Dietary habit-
106
1.Regular/Irregular/Fasting/Avg.Indian diet - First & second heart sounds are normally audible, No
2.Vegetarian/Non-vegetarian murmur & No added sounds.
5.Addiction
3.Alcohol-a.Amount/ day- b.Duration- 2.RESPIRATORY SYSTEM-Trachea is central,
4.Smoking- a.Nos- b.Duration- Chest is bilaterally symmetrical, Bilateral vesicular
5.Tobacco in any form breath sound is heard in all areas,No added sound.
6.Bowel
7.Bladder 3.LIVER & SPLEEN-Liver is not enlarged. Spleen
8.Allergies
is not palpable.
9.Contraceptive practice prior to pregnancy
H.FAMILY HISTORY K.ABDOMINAL EXAMINATION
1.Similar history in the family-Y/N I.INSPECTION

2.No history suggestive of TB, HTN, Diabetes, Multiple
pregnancy, Twin, Gynecological cancer (Ovarian cancer, 1.SHAPE OF THE ABDOMEN
Cancer of genitalia), Breast cancer, Known hereditary
disease,IHD,Blood dyscrasia etc. -Scaphoid/Protuberant OR Distended
2.UMBILICUS
I.GENERAL EXAMINATION a.Location-Midway between xiphisternum & symphisis

pubis/Displaced up OR down
1.She is conscious & cooperative b.Inverted/Everted
2.Height_______ cm c.Venous prominence around umbilicus
3.Weight_______kg
4.Body built-Average/Obese/Thin 3.CONDITION OF SKIN
5.Nutritional status-Good or Moderate/Average/Poor
*Moderately Nourished -Scar mark/Scratch mark/ Ulcer/ Ecchymosis/ Scaly/
Puncture mark
6.Pallor-Mild/Moderate/Severe
7.Edema of feet(dependent parts)- 4.VENOUS PROMINENCE
>Side-Bilateral/Unilateral
>Site-Dorsum of foot/Medial malleolus/Above the medial 5.ANY SWELLING
malleolus/ Medial surface of the lower end of the tibia/
Over sacrum a.Localised/ Generalised
8.Condition of skin-Scratch marks/Striae b.Intraabdominal/ Parietal
Leg lifting test ( Carnett’s test)
9.VITALS Blow out with nose & mouth shut
A.PULSE 6.FLANKS
a.Rate-____ Beats/min(Radial artery) -Full/Flat

b.Rhythm-Regular/ Irregular-Regularly irregular/ Irreg-
ularly irregular (or completely irregular)
II.PALPATION
c.Volume-Good Volume/ High Volume/ Low Volume
>Other points under the pulse(as described in medicine) 1.TEMPARATURE
are not told in obstetrics & gynecology.
2.TENDERNESS
B.BLOOD PRESSURE________mm Hg in the right arm
in supine position 3.RIGIDITY
C.RESPIRATORY RATE 4.GUARDING
a.____/min-Tachypnea/Bradypnea 5.ANY LUMP

Exclusively abdominal 1.Tenderness
2.Temperature
D.TEMPERATURE: _____F 3.Site
4.Size in weeks-12/16/24/28/30/32/34/36/40
J.SYSTEMIC EXAMINATION 5.Shape
6.Surface
7.Margin
1.CARDIOVASCULAR SYSTEM 8.Consistency-Solid/Cystic/Tense cystic

107
9.Mobility-Mobile from side to side/Mobile from above 6.SUDDEN GUSH OF WATERY FLUID PER VAGINUM
down
10. Lower border of the mass-Can be reached/ Can’t
be reached C.HISTORY OF PRESENT ILLNESS
! In general, lower border can not be reached in pelvic
tumors, but in a ovarian tumor with a long pedicle,
lower border can be reached. D.OBSTETRIC HISTORY
6.FLUID THRILL 1.GRAVIDA
III.PERCUSSION Gravida denotes a pregnant state irrespective of the
period of gestation, irrespective of the site of gestation
1.PERCUSSION NOTE ON THE MASS and irrespective of the outcome of the gestation.Twin
-Dull/ Resonant pregnancy is taken as gravida one.Ectopic pregnancies
are also included in the gravida.
>If the mass is cystic & huge, one can elicit a fluid
thrill felt with the flat of the hand placed on the one 2.PARA
side of the cyst while the cyst is tapped on the other
side with the other hand. Number of times the lady has undergone
parturition(including vaginal delivery as well as delivery
2.SHIFTING DULLNESS by caesarean section) beyond the period of viability i.e
beyond the 28th week of pregnancy that means
-Present/Absent abortions are not included under para.In other
words,parity denotes a state of previous pregnancy
>A pelvic tumor is dull on percussion with resonance beyond the period of viability.A woman who delivers
on the flanks. twins is taken as para one.A pregnant woman with a
>In presense of ascites, the flanks are dull on previous history of two abortions & one term delivery
percussion & shifting dullness may be present. can be expressed as fourth gravida but primipara i.e
>It is mandatory to test for shifting dullness in every para one.
cases of abdominal mass.
3.ABORTION
IV.AUSCULTATION
-Spontaneous/MTP
1.BOWEL SOUNDS
>Expulsion of conception before 28th week of pregnancy.
-Heard/Not heard >Mention the duration of pregnancy at which abortion
occurred.
>NOTE-Undergraduates are not allowed to perform
examination of the breast and pervaginal examination 4.LIVING CHILDREN
(PV examination).But write-Breast is normal on
examination. a.Number of living children-L1/L2/L3/L4/L5/L6/L7/L8
-Twins are taken as L2 but G1 i.e gravida one.
b.Boys-
c.Girls-
OBSTETRICS HISTORY TAKING d.Health status of each child/baby-They are healthy
e.Immunisation status of each child/baby-They are
adequately immunised
A.INTRODUCTION f.Last Child Birth(LCB)/Last issue-
1.NAME 5.EDD (Expected date of delivery)

2.AGE
3.RELIGION This is calculated according to Naegele’s formula by
4.SEX adding 9 CALENDER MONTHS & 7 DAYS to the first
5.FROM(Locality) day of the last noral(28 day cycle) period.
6.OCCUPATION Alternatively,one can count back 3 calender months
from the first day of the last noral(28 day cycle) period
B.CHIEF COMPLAINTS & then add 7 days to get the expected date of
delivery.The former method is commonly employed.
1.PAIN
2.PAIN WITH LEAKING *Typical description of obstetric history-She is
3.SAFE CONFINEMENT gravida 2,para 2 & had no abortion. She has 2
4.REFERRED CASE/DELAYED LABOUR children,1 boy of 5 year & 1 girl of 2 year,all are born by
5.ANTEPARTUM HEMORRHAGEACTIVE VAGINAL normal vaginal delivery at home(or hospital),all are
BLEEDING healthy & adequately immunized.The last child birth was

108
on 24th March,2006.The expected date of delivery is on *Clot in menstrual flow indicates heavy bleeding.It can
21st April,2008. also be determined by number of pads used.
I.HISTORY OF PRESENT PREGNANCY
a.COMPLAINTS F.HISTORY OF PAST ILLNESS

1.TIREDNESS 1.History of(H/O) similar attack in Past
2.EDEMA 2.No history suggestive of TB/HTN/Diabetes/RHD/
3.MORNING SICKNESS IHD/Jaundice/H/O contact with persons suffering from
4.GIDDINESS TB or any contagious disease(or Pt. is not a diabetic,not
5.BOWELS IRREGULARITY a hypertensive etc.)
6.BLADDER IRREGULARITY 3.Prolonged illness/Serious illness in the past
7.PALPITATION 4.H/O exposure to radiation
8.HEADACHE 5.H/O any surgery-a.Gynecological
9.ANY OTHER COMPLAINTS b.General
6.Previous H/O-
a.Blood transfusion-Yes/No
b.NO. OF ANTENATAL VISIT (BOOKING
b.Corticosteroid therapy-Yes/No
STATUS) c.Any drug allergy-Yes/No
d.Immunisation against tetanus-Yes/No
c.IMMUNISATION STATUS e.Prophylactic administration of anti-D
immunoglobulin-Yes/No
Number of tetanus toxoid received-1/2
G.PERSONAL HISTORY
II.PAST OBSTETRICAL HISTORY
1.Occupation
(This history is taken only in a case of multigravida.) 2.Socioeconomicstatus-Poor/Average/High income
*Fill up the first table given below. status
3.Marital status-Married/Unmarried/Widow/ Divorced/
Separated
E.MENSTRUAL HISTORY 4.Dietary habit-
6.Regular/Irregular/Fasting/Avg.Indian diet
I.PRESENT CYCLE 7.Vegetarian/Non-vegetarian
5. Addiction
a.Age of menarche 8.Alcohol-a.Amount/ day- b.Duration-
b.LMP(First day of the last normal menstrual period) 9.Smoking- a.Nos- b.Duration-
c.Duration of bleeding 10. Tobacco in any form
d.Length of the cycle(It is the interval from the first day 6. Bowel
of one period to the onset of the next period) 7. Bladder
e.Regularity of the cycle(Rhythm)-Regular/Irregular 8. Allergies
f.Associated clot 9. Contraceptive practice prior to pregnancy
g.Associated pain
II.PREVIOUS CYCLES
a.Duration of bleeding H.FAMILY HISTORY

b.Length of the cycle(It is the interval from the first day
of one period to the onset of the next period) 1.Similar history in the family-Y/N
c.Regularity of the cycle(Rhythm)-Regular/Irregular 2.No history suggestive of TB, HTN, Diabetes, Multiple
d.Associated clot pregnancy, Twin, Gynecological cancer (Ovarian cancer,
e.Associated pain Cancer of genitalia), Breast cancer, Known hereditary
disease, IHD, Blood dyscrasia etc.
*Mention about past menstrual history only if previous
cycles are irregular.Otherwise tell-Previous cycles are
regular.
I.GENERAL EXAMINATION
*Typical description-Menstrual period is 2-3 days in a 1.She is conscious & cooperative
cycle of 28-30 days duration,regular,not associated 2.Height_______ cm
with pain & clot. OR Menstrual period is 2-3 days in a 3.Weight_______kg
cycle of 28-30 days duration,regular & with average 4.Body built-Average/Obese/Thin
blood flow.(Average blood flow indicates it is not 5.Nutritional status-Good or Moderate/Average/Poor
associated with clot) *Moderately Nourished

109
6.Pallor-Mild/Moderate/Severe a.Location-Midway between xiphisternum &
7.Edema of feet(dependent parts)- symphisis pubis/Displaced up OR down
>Side-Bilateral/Unilateral b.Inverted/Everted
>Site-Dorsum of foot/Medial malleolus/Above the c.Venous prominence around umbilicus

medial
malleolus/Medial surface of the lower end of the tibia/ 3.CONDITION OF SKIN
Over sacrum
8.Condition of skin-Scratch marks/Striae -Linea nigra/Striae Gravidarum (Both pink & white)/
Scar mark/ Scratch mark/Ulcer/ Ecchymosis/ Scaly/
9.VITALS Puncture mark
A.PULSE 4.VENOUS PROMINENCE
a.Rate-____ Beats/min(Radial artery)

5.UTERINE OVOID
b.Rhythm-Regular/Irregular-Regularly
irregular/Irregularly irregular(or completely irregular) -Longitudinal/ Transverse/ Oblique
c.Volume-Good Volume/High Volume/Low Volume
6.UTERINE CONTOUR
B.BLOOD PRESSURE
-Fundal notching/Convex/ Cylindrical/ Spherical/
>________mm Hg in the right arm in supine position Flatened anterior wall
C.RESPIRATORY RATE
7.FETAL MOVEMENTS
a.____/min-Tachypnea/Bradypnea
-Seen/Not seen
Exclusively abdominal 8.UNDUE ENLARGEMENT OF THE UTERUS
D.TEMPERATURE: _____F II.PALPATION

>Never tell all the general examination points as
>PRELIMINARIES-Ask the patient to evacuate the
in medicine. Nobody is prepared to listen these in
gynaecology and obstetrics practical. bladder & then lie down in supine position with thighs
are slightly flexed.Abdomen is slightly flexed.The
examiner stsnds on the right side of the patient.
K.SYSTEMIC EXAMINATION
A.HEIGHT OF THE UTERUS (Fundal Height)
1.CARDIOVASCULAR SYSTEM
The uterus is to be centralized if it is deviated.The ulnar
-First & second heart sounds are normally audible,No border of the left hand is placed on the uppermost level
murmur & No added sounds. of the fundus & approximate duration of pregnancy is
accertained in terms of gestation.
2.RESPIRATORY SYSTEM Alternatively,symphysis fundal height(SFH) is measured
with a tape.
-Trachea is central, Chest is bilaterally symmetrical,
Bilateral vesicular breath sound is heard in all areas, No a.12 WEEKS GESTATION-Fundus is palpable just
added sounds. above the the symphysis pubis
b.16 WEEKS GESTATION-Fundus is palpable midway
3.LIVER & SPLEEN (Equidistant) between the symphysis pubis & umbilicus.
-Liver is not enlarged. Spleen is not palpable. c.20 WEEKS GESTATION-Fundus is palpable just
below the umbilicus.
L.ABDOMINAL EXAMINATION
d.24 WEEKS GESTATION-Fundus is palpable at the
I.INSPECTION level of umbilicus or just above the umbilicus.
1.SHAPE OF THE ABDOMEN e.28 WEEKS GESTATION-Fundus is palpable at the

junction of the lower third & upper two third of the
-Scaphoid/Protuberant OR Distended distance between the umbilicus & xiphisternum.At this
2.UMBILICUS time,the head is floating & is not engaged.

110
the back.the limbs & the anterior shoulder as mentioned
f.30 WEEKS GESTATION-Fundus is palpable midway above.
(Equidistant) between the xiphisternum(Ensiform
cartilage) & umbilicus C.EXTERNAL BALLOTMENT
g.32 WEEKS GESTATION-Fundus is palpable at the
3.PELVIC GRIP
junction of the upper third & lower two third of the
distance between the umbilicus & xiphisternum.At this
A.FIRST PELVIC GRIP (=PAWLIK’S GRIP=THIRD
time,the head is floating & is not engaged.
MANEUVER OF LEPOLD)
h.36 WEEKS GESTATION- Fundus is palpable at the
level of xiphisternum • Presenting part is grasped distinctly & is mobile
from side to side suggestive of nonengaged head
i.40 WEEKS GESTATION- Fundus is palpable at the
OR
junction of the upper third & lower two third of the
• Presenting part is grasped indistinctly & is not
distance between the umbilicus & xiphisternum i.e. the
mobile from side to side suggestive of engaged head
fundal height again drops to about 32 weeks position..At
OR
this time,the head is engaged & is fixed.
• Empty i.e nothing is felt suggestive of transeverse
B.OBSTETRICS GRIP lie.
1.FUNDAL GRIP >The palpation is done facing towards the patient’s

feet.Four fingers of the both hands are placed on the
• Broad,soft & irregular mass suggestive of head OR
either side of the midline in the lower pole of the uterus
• Smooth,hard & globular mass suggestive of head
& parallel to the inguinal ligament.The fingers are
OR
pressed downwards & backwards in a manner of
• Nothing is palpated
approximation of finger tips to palpate the part
>The palpation is done facing the patient’s face.the
occupying the lower pole of the uterus(Presentation).If
whole of the fundal area is palpated using both hands the part occupying the lower pole of the uterus is
laid flat on fundus to find out which pole of the fetus is head,then the aforementioned characteristics are noted.
lying at the fundus.
B.SECOND PELVIC GRIP (=FOURTH MANEUVER OF
2.LATERAL GRIP LEPOLD)
A.RIGHT • RELATIVE POSITION OF THE SINCIPITAL &

OCCIPITAL POLES-Sincipital pole is placed at a
• DETERMINATION BACK SIDE & LIMB SIDE- higher level than occipital pole suggestive of well
Smooth,curved & resistant feel suggestive of flexed head/Both the poles remain at the same level
back/Comparatively empty with small knob like suggestive of deflexed head OR
irregular feel suggestive of limbs. • SINCIPITAL & OCCIPITAL POLES ARE-Felt
• POSITION OF BACK-Placed anteriorly/Placed suggestive of nonengaged head/Not felt suggestive
towards flank/Placed transversely. of engaged of head OR
• POSITION OF ANTERIOR SHOULDER-Placed near • POSITION OF THE EXAMING FINGERS-
the midline/Well away from the midline. Divergence of the examining fingers suggestive of
• DISPOSITION OF SMALL KNOB LIKE engaged head/Convergence of the examining
IRREGULAR PARTS(LIMBS)-Placed to one fingers suggestive of nonengaged head.
side/Placed anteriorly occupying both the sides
>The palpation is done facing towards the patient’s
B.LEFT
face.The overstretched thumb & four fingers of the right
hand are placed over the lower pole of the uterus
• DETERMINATION BACK SIDE & LIMB SIDE-
keeping the ulnar border of the palm on the upper
Smooth,curved & resistant feel suggestive of
border of symphysis pubis.When the fingers & the
back/Comparatively empty with small knob like
thumb are approximated,the presenting part is grasped
irregular feel suggestive of limbs.
distinctly,if not engaged & also the mobility from side to
• POSITION OF BACK-Placed anteriorly/Placed
side is tested.In transverse lie the Pawlik’s grip is
towards flank/Placed transversely.
empty.
• POSITION OF ANTERIOR SHOULDER-Placed near
the midline/Well away from the midline.
• DISPOSITION OF SMALL KNOB LIKE C.SYMPHYSIS FUNDAL HEIGHT (SFH)
IRREGULAR PARTS(LIMBS)-Placed to one
side/Placed anteriorly occupying both the sides >The upper border of the fundus is located by the ulnar
border of the left hand & this point is marked.The
>The palpation (Lateral Grip) is done facing towards the distance between the upper border of symphysis pubis
patient’s face.The hands are to be placed flat on either upto the marked point is measured by a tape in
side of the umbilicus to palpate one after the other,the centimetre.
sides & the front of the uterus to find out the position of >After 24 weeks of pregnancy,the symphysis fundal
height measured in centimetre normally corresponds to

111
the period of gestation in weeks upto 36 weeks.A
variation of +/- 2 cm is accepted as normal.Variation
GYNAECOLOGY CASES
beyond the normal range needs further evaluation.
D.GIRTH OF THE ABDOMEN AT THE LEVEL OF

THE UMBILICUS 1. FIBROID (IMPORTANT)
2. DUB (IMPORTANT)
>The girth of the abdomen is measured at the level of 3. PROLAPSE (IMPORTANT)
4. OVARIAN TUMOR (RARE)
the umbilicus.
5. POSTMENOPAUSAL BLEEDING (IMPORTANT)
>The girth increases by about 2.5 cm per week beyond
6. CERVICAL EROSION
30 weeks & at term measures about 95 to 100 cm. 7. CARCINOMA OF CERVIX (IMPORTANT)
8. CARCINOMA OF ENDOMETRIUM
E.FETAL MOVEMENTS
III.AUSCULTATION
FETAL HEART SOUND OBSTETRIC CASES
1.Site
2.Rate 1.ANTENATAL CHECK UP (IMPORTANT)-
3.Rhythm DIFFERENT PRESENTATIONS
4.Intensity 2.PUERPERIUM (IMPORTANT)
3.PUERPERAL PYREXIA (IMPORTANT)
NOTES ON ABDOMINAL EXAMINATION-Fill up the 3.POST CEASAREAN PREGNANCY
second table given below 4.PREMATURE RUPTURE OF MEMBRANE (PROM)
1.Position-OA/LOA/LOT/LOP/OP/ROP/ROT/ROA 5.PRE-TERM LABOUR
2.Lie-Longitudinal/Oblique/Transverse 6.POST MATURITY ( > 42 WK)
3.Attitude-Well flexed/Deflexed
7.TWINS
4.Presentation-Cephalic/Podalic/Shoulder
8.PRE-ECLAMPSIA
NOTE-Undergraduates are not allowed to perform
9.ECLAMPSIA
breast examination and pervaginal examination (PV ex-
10.POSTPARTUM HEMORRHAGE (IMPORTANT)
amination). But write-Breast is normal on examination.

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1

FUNDAMENTALS OF HISTORY TAKING & CLINICAL EXAMINATION

B.CHIEF COMPLAINTS WITH CARDIO VASCULAR SYSTEM (CVS)

>Chief complaints are noted in CHRONOLOGICAL ORDER 1.Duration

ILLNESS 3.BREATHLESSNESS (DYSPNEA)

a.When you are apparently well or asymptomatic? 1.Duration

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

GRADE OF BREATHLESSNESS OR DYSPNEA 1.Type-Generalised tonic-clonic/ Absense

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

1.Duration 9.HOARSENESS OF VOICE

4.CHEST PAIN 1.Duration

5.BREATHLESSNESS (DYSPNEA) • Site

VOMITUS • Site-Face/ Leg

13.OLIGURIA 1.Altered Sensorium

• Duration 3.MOTOR FUNCTION

• Duration 1.Proximal Weakness

2.Distal Weakness ! VOMITUS

B.TONE-H/O of stiffness of the limbs 8.CONVULSION

C.WASTING OF MUSCLES-Proximal/ Distal 1.Duration

1.Swaying/ Unsteadiness/ History of falling 5.RED COLOR URINE (HEMATURIA)

17.SLEEP DISORDER 1.Duration

2.HEMORRHAGIC SPOTS 1.Duration

3.BLEEDING DIATHESES 1.Duration

5.MORNING STIFFNESS >Tell that the pt is habituated to pan & addicted to

HEMIPLEGIC DECUBITUS-The affected arms remains 6.CYANOSIS

ABDOMINOJUGULAR REFLUX=HEPATOJUGULAR REFLUX 8.LYMPH NODE ENLARGEMENT

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

2.SECOND DEGREE >For detection of clubbing, first examine the

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

EXAMINATION FOR PARIETAL EDEMA HAIR CHANGES IN PROTEIN-ENERGY MALNUTRITION

>Edema can be recognised by the pallid (i.e pale) & b.NAIL

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

17.OTHERS RELATIVE TACHYCARDIA

c.PAROTID SWELLING b.RHYTHM

d.GYNECOMASTIA (Spacing of successive beats in time in Radial artery)

a.RATE PULSE DEFICIT = APEX-PULSE DEFICIT

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

Water hammer pulse is best felt in the radial artery with

2.SUPERFICIAL TEMPORAL ARTERY 4.POPLITEAL ARTERY

• Wrist is slightly flexed & forearm is semipronated. 5.FEMORAL ARTERY

It is a feature of atherosclerosis. For demonstration,

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS ≥18

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

C.THRILL (Palpable Murmur) A.PALPABLE A2

1.SYSTOLIC B.PULSATION-Present/ Absent

Synchronous with the carotid pulsation or apex beat, e.g C.THRILL

A.PALPABLE P2 1.I-Felt but hand not lifted

B.PULSATION-Present/ Absent >Parasternal heave is the anterior movement of lower

III.PERCUSSION 1.Optimise acoustics

• P2-Pulmonary component of second heart 2.MURMUR

POSITION OF THE PATIENT e.g Hypertrophic obstructive cardiomyopathy

Before auscultation, localize the apex beat by palpation b.DIASTOLIC

>OBSTRUCTIVE MURMURS produced due to obstruction TYPICAL DESCRIPTION OF MURMUR

h.PERICARDIAL FRICTION RUB

WRITTEN BY Dr. SUMANYU KUMAR TRIPATHY, MOB-08976130574, e-mail-sumanyu258@gmail.com

F.HEARD BEST WITH The Graham Steell murmur of pulmonary regurgitation

E.POSITION c.CONTINUOUS (=SYSTOLO-DIASTOLIC)

-Bell/ Diaphragm of the stethoscope

a.SYSTOLIC 3.ADDED SOUND

EJECTION SYSTOLIC (=MID-SYSTOLIC) D.TRICUSPID AREA