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GENERAL EXAMINATION
Always greet and introduce yourself, take consent (before producer) and ask for a chaperaone in your patient is a female, stand on the right side
1. General Appearance
- Patient position (propped up, supine, left lateral), receiving oxygen, IV cannulae, Uro bag, chest tube (mention drainge) in distress?
- Pt. Mental and emotional state (TPP)
- Pt. Facies, complexion, Odor, Pt. voice (Hoarse), Resp. sounds (wheeze), Abnormal Movement (tremor) Nutrition (skin loose or not, hair shine (luster), colour, angular stomatitis)
2. Vitals
a. Temperature:
i. In axialla for 2 minute (3 in paed), bulb at the root of the Axilla (best place is external auditory canal)
ii. Normal oral temp (936.4-37.2°C (Harrison)), Hyperpyrexia (41.6°C, 107°F), Hypothermia (3??°C – 95°F), Axillary temp is 0.5°C lower than oral.
b. Pulse
i. 15s (posting) and 30s (Hutchison) rate and rhythm in Radial Artery
ii. Radio-radial and radio - femoral delay (must acc to Prof. F.C. Ghami)
iii. Character and volume in Carotid
iv. Peripheral pulse (optional but done in CVS)
c. BP: Keep hand instrucment a heart level, tube overbrachial artery (Mind the a cannula) both hands (optional but done in CVS).
d. Respiratory rate (14–18): Act like you are taking pulse and count for minute. Breathing regularity, accessory muscle use breathing pattern (abdominal thorasic in male and thoraco abdominal in females and children.
3. Pilccod:
a. Pallor:
i. Lower palpebral conjuctiva, tongue tip and dorsum, plams (if the plamar creases are higher in color than the surrounding skin when the hand is hyper extended, the hemoglobin level is usually <80 g/L (8p/dL). Harrison).
ii. Pallor without anemia: Hypothyoidism, 'Hypopituitarism, Shock, Thick skin, Anasarca Kundu.
b. Icterus: Seen in daylight, upper conjunctiva (eident at 3mg/dl or 51 micromol Harrison. Look at bulbar conjunctiva (differentiates icterus from (carotenaemia which occurs in hypothyrodism, diabetics, people who eat great quantities of carrots - hutchisons) ventral (under surface) tounge and skin apperance.
c. Lymphadenopathy:
i. Cervical > 1.5cm (harsion 1 cm): From behind examine the submental, submandibular, pre auricular, tonsillar (at the angle of mandible), cervical glands and supra clavlcular in ant triangle of neck. From the front of the patient examine the post auricular and occipital nodes and down the back of the neck (posterior triangle0.
ii. Axillary (> 1cm posting): Use right hand when examination of left axilla vice except for lateral group (and psoterior for easiness) of lymph nodes. Comment on site, consistency, tenderness and fixation.
iii. Inguineal (>2cm Harrison) in a T shaped fashion (epitrochlear is optional).
d. Cyanosis: Bluish discolouration of skin and murcus membrance due to reduced Hib > 5gm/dl (Macleod's). Think thrice before saying cyanosis in a anemic patient with Hb less than 8gm% for both central & peripheral cyanosis.
Saturation in light skinned should be <85% dark skinned < 75%.
D/Dx methhemoglobunemia (due to dapsone), sulfurhemoglobunemia, and phenacetin (drug).
e. Clubbing: Finger at your eye level – look at the windown of Schamorth an the transverse/A.p. diameter
∙ Grade I– Loss of normal angle between nail and nail bed > 165, increased nail bed fluctuation.
∙ Grade II – Increased transverse and ant-post diameter.
∙ Grade III – Increased pulp tissue – drum stick appearance of finger
∙ Grade IV/Pulmonary osteoarthropathy wrist and ankle swelling (if cubbing present look at wrist, ankle and elbow).
∙ For signeficance clubbing should be bilateral, if unilateral look for local cause (posting)
∙ Look for the Schamroths sign (window created between two thumbs).
∙ Also look for differential clubbing at the feet (PDA) - remember 10 causes (RAUT)
∙ Thyroid acropachy, clubbing note on radial side (Macleod's)
f. Oedema:
∙ Palpate above & behind (just above over the skin in posting) medical malleoli (the mitdest odema first manifests behind medial malleoli overy bony prominences) and over the sacrum (palpate 20–30s) – Hutchison's.
∙ According to postings, you have to press at the shin at the jxn. Between lower 1/3 and upper 2/3 of the shin of Tibia bilaterally for 15s.
∙ In anasarca oedema over sternum and forehead (Kundu)
∙ Non pitting oedema (VIVA) – Scleroderma, Myxoedema, Angioneurotic, Lymphatic (SMAI)
g. Dehydration: Look in neck and trunk also inspect oral cavity for moistness. Think twice before saying dehydration in edematous patients (Raut).
h. JVP (9cm of water corresponds to 6mm Hg in Harrison 8cm of blood)
∙ A positive Abdominojuguarl test is best defined as an increase in JVP during 40s of firm right Hypochondrial compression followed by a rapid drop in pressure of 4cm blood on release of the compression, in normal person's, this maneuver does not after the jugular venous pressure significantly, but when right heart function is impaired, the upper level of venous pulsation usually increases (Harrison).
∙ Look for rise, waves and refluxl
∙ Raised in heart failure, Pulm. Emb, Pericardial effusion, pericardial constriction (Russmul sign) SVC obstruction also loss of pulsation.
∙ A wave - right artrial contraction (absent in AF, glant in TS pulm HTN, cannon in complete HB)
∙ C wave – closure of tricuspid, and transmitted carotid pulsation.
∙ X–Descent – atrial relaxation.
∙ V–Wave – Ventricular contraction (filling of right atrium) giant in TR.
∙ Y–Descent – Right ventricular filling.
4. Head to Toe
a. Hair (3 phases of growth anagen – 85% catogen and Telogen – 15%) (Inspect and gently pull)
b. Face: Pigmentation, asynmetry, paroid swelling, chelitis in lips, rashes (molar rash), eye redness (indicts common in CTD), exophthalmus, ear discharge, mastoid swelling (optional meningitis).
c. Neck: Vessels, thyroid swelling (inspect, swallow and palpate (from back) (yes thyroid examination is done roughly in general examination acc to Hutchison's but of course it is optional).
d. Breast: Gynaecomastia, Splder naevl (upto 5 normal, in macleods) upto 7 normal in young adults, but in older age, OCP use and liver disease it may increase (Hutchison's) also look for axillaries and chest hair (must in GI cases).
e. Hand: Inspect (Erythema 'liver palms' in pregnancy and liver disease) shake hand (warmth, peripheral coolness), muscle wasting.
f. Nail: Koilonychias, Leukonychia (Hypoalbuminemla), Splinter haemorphages (IE, RA, Psoiasis, Trauma), yellow nail, syndrome (Posting Q's), Beau's lines, Joints (deformity, tenderness), Duputren's contrature, thickening and shortening of palmar fascia resulting in flexion deformity.
g. Skin: Rashes and pigmentation (Lower limbs & joints included, pretibial myxedema, venous dilations, calf tenderness).
h. Back examination: KYphosis, scollosis, pigmentation. Always take the opportunity of turning the pillow over before lying the pt. back again, a cool fresh pillow is a great comfort to an ill person – Hutchison's.
Respiratory System
In general examination look for breathless stress, Wt. loss (COPD, cancer), mental state (narcosis), breathing pattern accessory muscles, breath noises, purse lips, horner syndrome, look for scalene L/N which si the 1st sign of lung Ca metastasis (Macleod's), yellow nail syndrome, Asterexis JPV (Cor pulmonate) venous prominences (SVS obstruction, SVP non pulstile) Rashes and nodules (inflame disease). If pt producing cough look at sputum (in plastic) optional.
Pt. position is important since in distress pt. will be propped up and in pleural effusion pt will lie on the effected side.
Asterexis (alternate method is ask pt to squeeze middle, index finger and tell to hold position for 30s (Yogi sir).
Co, retention, warm peripheries, bounding pulse, Astrexis URT (all guff but miss this in paed).
Nose (Congestion, polyp, flaring) PNS (ask pt to lean forward and palpate in Brochieclasis there is an association with immotile cilla leading to recurrent sinusitis) ear discharge, mastroid swelling, throat, yellow nail syndrome.
Thorax
1. INSPECTION: Pt should be in sitting position (if not in distress), inspect all areas of the chest and, lat and post. If possible take consent and remove 'ant. section' (don't remove undergarments) of the clothes maintaining privacy. Remember female patient, female attendant.
a. Look for deformities, intercostals fullness (effusion and depressions, Apical impulse, venous prominences, interocstal recession, any rash, mark, pectus excavatum (apical impulse can be displaced), carlnatum + Harrisons sulc (vit. D def and hyperinflation). If back look for kyphosis (decreases vital capacity) Scoliosis, Gibbus.
b. Chest shape (Barel shaped) (Normal chest is B/L Symmetrical and elliptical in c/s)
c. Symmetric (took at Nipple, shoulder, Scapular and from the back of the pt at the level of pt head looking, downwards – Raut).
d. Look at respiratory pattern and movements thoracic, abdominal and paradox).
e. Trail sign – Strenornastoid muscle prominent due to deviation of Trachea. (Optional).
g. Also look for epigastric impulse (R).
2. PALPATION:
a. Position of mediastinum (Trachea position, and apex beat).
b. Tracheal Tug (fingers resting on trachea moves down with inspiration).
c. Distance between cricosternal, distacne (3 fingers)
d. Measures the AP and Transverse diameter, Normal is Transverse:AP 7.:5 (in barrel shaped chest Transverse:AP is 1:1, and is circular in cross section)
5. Temperature and Tenderness, Apex Beat (leaning forwards), if swelling describe.
6. Movement of chest
i. At the level of Nipples
ii. Go behind and keep hands on the apex with your thumb at the neck and watch for lifting of plams.
iii. Keep hands vertically side by side between the scapular.
iv. Intrascapular same as anterior
7. Chest expansion: Maximum difference between inspiration and Expiration. Normal is 5 - 7 cm. Do it with measuring tape..
8. Vocal Fremitus.
3. PERCUSSION (AUENBRUGGER):
Sitting position, Most resonant is inter scapular and infra clavicular. Start anteriorly with Supraclavisular fossa in horizontal position. Percuss symmetrical on the other side.
Percuss on clavicle (use finger)on medial third. Go on the Midclavficular line upto 7th IC space comparing both sides. Liver dullness on the right 5th ICS.
Similary Percuss on the Mid axillary line upto 8th IC (put pt hands over his head)
Posteriorly: Ask pt to fold hand to incrase the inter scapular area, then percuss starting from apex (kronigs Space) put finger perpendicualr to clavicle and percuss at three sites. (Kronigs space is obliterted in apical TB, Pancroasis tumor)
Then percuss as anterior upto 11th rib).
Shifting Dullness - Pt in supine position chest will be resonant seen in hydropneumothorax. Kundu (very optional)
Cardiac dullness will be obliterated. Decreased in Hypernflation (Medicine cont)
4. AUSCULATION
Pt should face the left breathe through the mouth.
1. Auscultate Ant:Supraclavicular, supra Mamary, Mammary and infra mammary.
Axillary; Upper, Middle, Lower.
Post: Supra, Inter and Infra scapula
Listen to quality, amplitude, gap between inspiration and expiration and added sounds
2. Vocal Resonance.
SPECIAL SEGMENT
BREATH SOUNDS:
VBS:
∙ Sound produced by the passage if air in and out of the alveoli (Kundu)
∙ Its rustling, inspiration duration longer than expiration
∙ No gap in between.
∙ VBS with prolonged expiration seen in coped (RAUT).
Bronchial:
∙ High pitched with a follow on following quality intensity is similar and the durations is same in both inspiration and expiration Gap in between.
∙ Found in Consolidation, Collapse, fibrosis, and above the pleural effusion.
Types (Asked in 7.3rd batch viva)-kundu
a. tubular - High pitched found in Consolidation, collapse, over pleural effusion.
b. Cavenous- Low pitched found in cavity (TB, abscess)
c. Amphoric- low pitched with metallic tone this sound mimics whistling sound produced by blowing air across the mouth of a small glass bottle. Seen in bronchopulmonary fistula.
Decrease breath sound; In obesity, Effusion, Huckening of pleura, pneumothorax, Hyperinflation collapse where the bronchus is not patient.
Risk pt to cough - breath sounds more audible - due to obstruction due to secretion (Macleods)
Aegophony - Nasasl Sound over consolidataion.
Whispering pectontoquy.
ADDED SOUNDS
According to Hutchison's only wheeze and crackies other (Raies, Rhonci) avoided.
But in Harrison.
Wheezes, which are generally more prominent during expiration than inspiration, reflect theoscillation of air way wall that occurs when there is free liquid or mucus in the air way lumen; the viscous interaction between the free liquid and the moving air creates a low - pitched vibratory sound.
Stridor, which occurs primarily during inspiration, represents flow through a narrowed upper any way, as occurs in an infant with group.
Crackles (Roles) are the discontinuous, typically aspiratory sound created when alveoli and small airways open and close with respiration.
Hutchisions
Wheeze: Musical sound due to airway narrowing, inspiratory wheeze means sever airway narrowing (Macleods), in very severe asthma absent wheeze (Asthama, Bronchitis, FB, Tropical Eosinophilia, Carcinoid - Kundu)
Crackles: Short explosive sounds which are described as bubbling (Hutchison's).They are caused by sudden changes in gas, pressure related to the sudden opening of previously closed small airways. (Posting Ques,) Fine crackles seen in pulmonary fibrosis (but in kundu, Davidson line crackes also seen in LVF)rest are coarse (bronchractasis, Abscess, Pneumonia). Biphasic crackles seen in Bronchiectasis (Macleods).
∙ Ask pt fo cough. Crackles will be heard - post tussive Crackles heard in cavity ???????
∙ Timing of Crackes - Bronchitis, Bronchiactasis, abscess, Fibrosis, Pulmonary oedema
∙ Expiratory Crackles - Air way obstruction (Asthma).
∙ Pleural Rub: Rough heathery sound best heard with diaphragm at end of deep inspiration due to Priction of inflamed parietal and visceral pleura.
∙ Pneumothorax click (Macleod's )rhythmical sound synchronous with cardiac systole d/t air between two layers of pleura overlying the hearth.
Wheeze Types (posting)
i. Polyphonic Wheeze - Bronchil Asthams due to generalized bronchospasm
ii. Monophonic Wheeze - Localised Bronchospasm due to infection.
In General Examination:
∙ Obesity (truncal,generalized), xanthomata malar flush (D/DX MS polycythemia, SLE (more of a rash), cushings, skin disorders ( acene rosacea, closasma) - RAUT ) Corneal Arcus (Senile arcus). Splinter hemorrhages, Petechiae in conjunctiva, Venous prominences. Thyroid enlargement.
1. Vitals (Don't forget to repeat BP, Pulse, JVP again).
a. Pulse
Pulse Deficit: Difference between the heart rate and pulse (1st count the heart rate for 1 minute and then the pulse in the next for ectopics, AF or digitalized AF. If Deficit is > 10 it is AF, but if < 10 it may be ectopic or Digitalised AF. To differentiate between the two ask pt to touch toes and back 5-6 times then measure pulse deficit again, if > 10 AF if < 10 Ectopic - Kundu).
∙ Pulsus Bigerninus - 2 beat and a pause (2nd beat is ectopic)
∙ Pulsus Alterans - beat tobgeat variation (in advanced heart failure)
∙ Pulus Bisferans - Two peaks in systole (combined AS and AR, AR, Hyperptophic Obstructive (CM)
∙ Anacrotic pulse- Upstroke in descending limb 2nd week of typhoid.
∙ Peripheral pulses.
b. BP
Measure pressure of both arms
∙ Posturalo drop - Measure supine then standing after 3 minutes (SBP > 20DBP>10 ) in hutchisons > 30).
∙ PulsusParadoxus (and Inspiratory fall by 15mm Hg (Macleod's) 10 mm Hg (Hutchison's - optional. Occurs in Tamponade, Constrictive pericardisis, Obstructive pulmonary disease.
2. Inspection
∙ 45° (according to Macleod's ). Inspect back also for scoliosis.
∙ Shape Bulging. VSD, RHD, effusion, flattening - fibrosis.
∙ Apex impluse, Veins, Scars, Epigastric pulsation (TR.Aneurisms), Suprasternal(AR/Aortic arch Aneurisms). Carotid pulsation.
3. Palpation
a. Mitral area: Obtain general by putting your whole hand flat overthe precordium then locate the apexibeat by fingers. If you don't fing it first lean the patient forward forward and then palpate again. If you fall here also palpate on the right side to look for Dextrocardia. (Kundu).
Metion site, character heave, (LVH) lap(MS representing second HS), double apical impulse (HOCM) and thrill (normal is mid tap acc to kundu)Diastolic thrills are rare
b. Tricuspid area: Palpate lower Left Parasternal area for heave with ulnar border (RVH), thrill (VSD, TR)
c. Pulmonary and Aortic Area: Palpate thrill, palpable heart sound.
4. Percussion (Optional)-
- Obsolete acc to postings
- Percuss the 2nd IC space if dull suspect pericardial effusion (Kundu)
5. Auscultation (Pt. In 45 Degree)
45 Degrees acc to Macieod since pt. may be experiencing orthopnoea and easier to lean the pt. forward when required.
a. Mitral Area listen with diaphragm first then switch over to bell. (In both at the height of expiration) then turn the pt over to left lateral position and listen with diaphragm and bell again at height of expiration. If a murmur is heard,listen at the left axilla (MR) and Infra scapular area. Palpate Carotid when auscultating to determine timing.
- Listen 10.53 which is an early diastolic sound best heard at apex with bell which coincides with rapid ventricualr filling. Normal in children, young, adults and pregancy. Pathological after 40 years. This is AKA gallop (LVF, MR) 54 best heard with bell at apex always pathological due to forceful atrail contraction against stiff ventricles. (LV hypertrophy, HTN, AS).
b. Tricuspid Area (left 4th IC - Kundu)
- Listen with diaphragm then switch over to bell (Both at height of inspiration ) look for TR in COPD.
c. Pulmonary Area(Left 2nd IC)
- Sit the Pt. up and lean him forward (this is an ideal time to inspect the back), at height of inspiration auscultate with diaphragm and bell.
d. Arotic area(right 2nd IC)
- Same as pumonary area but at height of expiration, if murmur is heard listen at carotids (As)_
e. Neoaortic Area(left 3rd IC, Erbs point)
- Same as aortic, best plance to listen for AR again at height of expiration After this when pt is leaning forward you can auscultate over the over the left lower parasternal area for pericardial rub, here ask the pt to hold his breath and the rub will continue).
- If AR noticed look for peripheral signs also (17 of them)
Mumurs(Special Segment)
Describe the Murmur
1. Timing and Duration
2. Pitch and Character
3. Intensity (Grading)
4. Site
5. Heard best with what part of stethoscope
6. Association with respiration and Position
7. Radiation
For example sir, I hear a Pansystolic Murmur of high pitch and blowing in character, Grade III Intensity, heard best at the mitral area with the diaphragm, at the height of expiration and left lateral position which radiates to the left Axillae.
Grade of the Murmur (Harrisons)
1. Soft, only with great effort(Heard by an expert in optium conditions)
2. Easily heard, but not loud (Heard by a non -expert in optimum condition).
3. Loud but no thrill
4. Association with thrill
5. Heard with the edge of the stethoscope touching the chest
6. Heard with stethoscope off the chest
Innocent Murmur - heard in the pulmonary area, mid systotic, may disappear in upright position, no thrill, in pregnancy, athletes, (kundu)
Haemic Murmur - ejection systolic murmur heard when patient develops hyperkinetic circulation seen in anemia. (May be due to increased flow increased flow through pulmonary value or dilation of pulmonary artery. (Kundu).
Added Sound
1. Opening snap - early diastole, apex - MS (LOMP)
2. Ejection Click - just after S1 (in PS and AS)
3. Mid Systolic Click - Mitral valve prolapse.
4. Rub- Leathery sound, heard best at left lower parasternal area, intensitiy increases when patient sites and leans forwards, with daiphragm, sound continues even after poldide breath.
5. Auscultate in the inter scapular areas if you are suspecting coarctation of aorta, you will hear a systolic bruit.
- Machinery Continuous Murmur -PDA, look for Volume peripheral pulses.
GI and Renal System
∙ In general Examination: Nutritional status, Smell (fetor hepaticus), Scratch marks (CRF, Obstructed Jaundice), Asterexis (Hepatic encephalopathy), Dialysis mark, A v fistula (CRF ), fluid Overload (JVP), Brown Pigmentation of nails (Half brown half white in CRF), Virchows Lymph node.
∙ Diabetes: Acanthosis Nigricans, Look for signs of other autoimmune diseases (Thyroid, Vitilligo), Insulin injection sites and lipohyperthrophy, Trophic ulcers, callus foot.
∙ Stigmata of chronic Liver Disease: Spider Nevi (up to normall (macleod's ) utp to 7 normal in young adults, but in older age, OCP use and liver disease it may increase (Hutchison's), Palmar erythema, Gynaecamastia, Caput medusae, Dupuytren's contractures, Parotid gland enlargement and Testicualr atrophy - Harrison.
∙ (+ Lcterus, Clubbing, Hepatomegaly, Ascites, Leuconychia, loss of body hair,Breast atrophy - Macleod's)
Oral Cavity (all Guff) - Use tongue depressor:
1. Lips, Corners of the mouth (Angular Stomatitis, fissures and cracks)
2. Teeth - discoloration, overall general hygiene,
3. Gums - Healthy or not (gingvitis), bleeding
4. Tongue - Beefy tongue (MBA), Large tongue (Acromegfly, Cretinism, Amyloidosis), Atrophic glossitis in IDA), Coating of tongue in typhoid 51 - 56% (RAUT)
5. Buccal Muscoa - Ulcers, Parotid duct , candidiasis.
6. oro Pharynx - Tonsils, Congestion
7. Breath - Halitosis
8 Palpation - use glove and palpate floor of mouth ( very optional)
INSPECTION
∙ Two Vertical lines - Mild clavicular line to fermoral artery (Mid point o9f inguinal ligament)
∙ Two Horizontal Lines - Tubercles of lliac crest and lower most point of costal margin
∙ Always ask if patient has urinated as bladder can hinder palpation.
∙ Pt. Supine, use two pillows to relax the abdomen, Adequate exposure - just above xiphisternum to mid thigh (Hutchisons), from Nipple to mid Thigh (Nepal to Thailand -Raut), condsider ethical scenario and expose only upto pubis and later inspect the genitalia.
1. examine the abomen for 30s (Hutchison's ) from different sides, your eyes at the level of abdomen. Normal shape of the abdomen is - normal contour and fullness. Look at flanks (measure abdominal girth at umbllicus - opt.
∙ Umbilicus -Nor4mal is retracted and inverted and center, also measure umbilicus distance from xiphisternum and pubis. Xiphisternum to umbilicus is more than the distance between umbilicus to pubis (Tanyol's sign) in aspites. In ovarian Cyst it increases the other way - Prof. Pradeep Shrestha (PS).
2. (fisth Mouth/slit like & everted umbilicus in Ascites, vertical slit in ovarian Cysr- Kundu).
3. Skin - In distension smooth and shiny, Striae, venous prominences (IvC Obstruction the veings are circumflex illac, Sup Epigastric, Lat Thoracic, Axillary - important Acc to PS), Scar marks, Pigmentation, visible pulsation and peristalsis.
4. Movement with respiration with your eye at abdomen level (remeber Balley) 5'Fs Fluid, Faecbus, Fetus, Flatus, Fat (add to that Fibroid and Full bladdeeracc to Kundu).
5. Inspect the groins testis, pubic hair, hernia orificess, then bring the sheet overt the genitals.
PALPATION:
Relax the abdomen wall by flexing the legs. Pt arms on the right slide. Ask if the patient feels any pain so as to palpate that position at thelast. Now warm your hands.
1. Proceed with superfical palpation looking for temperature mass and guarding (starting from left illac fossa. Your palms and elbow should be at the same level to the abdomen even if it means kneeling, witch the patients face) First with the dorsum of your hand look for temperature then palpate for tenderness. Go in an anti clockwise direction ending at the suprapubic region.
2. Look for the low of the veins (Away or towards the Umbilicus)
3. If mass present (DAS)
4. Deep Palpation same method as superfical then palpate for organomegaly. (in Hutchison left kidney is started first but in our setting we start with Liver).
5. Liver:
∙ Hand in RIF parallel to subcostal margin feel with radial border, press hand inwards and upward at the height of inspiration and left the liver hit. (Hutchison) if not palpable move your hand us in expiration (Kundu).
- Use dipping method in case of ascites.
- Note for size surface edge, consistency, tenderness, pulsation (using bimanual method - TR) and movement with respiration. Also mention how many cm/fingers below costal margin.
- Next look for liver span by percussion normal is 12 - 14cm (posting)
- D/Dx tender liver - Hepatitis, Abscess, Hydatid cyst, Cardiac Cirrhosis, Budd chiari syn (Dr.SMA)
6. Spleen
- Place the left hand postero laterally over left costal margin and press it forward and medially. Ask pt to breath in deeply palpate starting from RIF move upwards and towards the left hypochondrium (along spienic growth axis). If not palpable turn the pt. to right lateral position ask them to relation your left hand which is now supporting the ribs and repeat. It may be helpful to ask the pt to place left hand on right shoulder.(Hutchison ) pt will also flex his knee and hip in right lateral position.(Kundu)
- In Ascites use the dipping method.
- In just palpable spleen use the hooking method, 'left 'side of the patient facing supine end of bed, palpate spleen with hooked fingers of left hand below left costal margin.
- Note same as liver .
Difference between Spleen and Kidney.
∙ Percussion: Costell's method: With the patient supine, percussion in the lowest intercostal space in the anterior axillary line (8th or 9th) produces a resonant note if the spleen is normal in size. This is true during expiration or full inspiration. A dull percussion note on full inspiration suggests splenomegaly. (Harrisons).
∙ Traubes Space: The borders of Traube's space are the sixth rib superiorly (left dome of diaphragm), the left midaxillary line laterally, and the left costal margin inferiorly . The patient is supine with the left arm slightly abducted. During normal breathing. This space is percussed from medical tolateral margins yielding a normal resonant sound. A dull percussion note suggests splenomegally. Harrisons) Normally Traubes space contains the gastric fundus, the tympanicity is lost in Ca fundus, Splenomegally, Left pleural effusion, enlarged left lobe of liver, achalasia cardia (fundus absent) - Kundu.
∙ Massive Splenomegaly - >8cm from LCM or > 1kg (Harrisons)
∙ Causes: Malaria, Kala Azar, CML, Myelofibrosis, Cll Gauchers, sarcoldosis, Thalasemla, Autolmmunt hemolytic anemia.
7. Kidney
- Right hand above lumbar and left hand placed posteriorly/ loin. And push left hand above to ballot.
8. Urinary bladder (optional)
9. Aorta and Lymph nodes
- Above and left to umbllicus use your 'finger's and then to right to palpate both wall of aorta.
- Also palpate para - Asortic lymph nodes.
10. Palpate hernia orifices, testis, spermatic cord.
11. Renal Angle tenderness. Just hit with fist tat renal angle (lateral to Frector Spinae and lower border of 12th rib).
PERCUSSION:
1. Percuss from epigastirc region down to umbllicus, then turn your fingers parallel to longitudinal /spinal axis and percuss laterally if you find dullness continue to make it sure that it's not a localized dullness (colonic growth or fecolith) and then the come back to the initially noted dullness. Now turn the patient to right lateral position keeping the fingers at the point of dullness for at least 10s (Kundu and Macleods), now percuss again and it will be resonant,now percuss to the other side and find the point of dullsness. Repeat on other side (amount of fluid required - 1/2L to 1L).
- Unilateral Shifting dullness seen in hemoperitorieum due to splenic injury (Ballance's sign), in Puddle sign, fluid required is 300 -400 normally but even 120 ml (Kundu).
2. Fluid Thrill make sure you ask the pt to keep hand over the abdomen (midline ) amount of fluid required is 2L(Kundu), in tense Ascites you will only find fluid thrill.
AUSCULATATE.
1. Right of Umilicus of Bowel sounds listen for 1 minute. Normally 7 -9 per minute (Posting)
2. Listen to Bruit of Aorta left to the umbillicus and then to bruit's over spleen (Splenic infarction in SBE, CML, Sickle cell anemia) and Liver (Hepatoma).
3. Listen to either side of the midline of the abdomen for renal artery stenosis exp. In HTN.
4. Listen to any venouw hum over dilated abdominal veins, and a loud venous hum at umbilicus with normal liver is called ' cruveithier baumgarten syndrome' (Prof. PS. Theory class), this may be due to well compensated cirrhosis or congenital patency of umbilical vein (Kundu).
5. Succulion splash (after 3 hours) -optimal.
- P/R (Tell frankly if you haven't done) .
∙ In General Examination: Which handedness (useful in aaphasia), Carotid bruit, Posture, Facies (7th Cn Palsy, Ptosis, Mask like, facles), Tremor, Ear Discharge, Mastoid swelling (Meningitis), Pes Cavus (Famillial peripheral neuropathy), Skin infectious neuropathy), Back (Gibbus, any swelling , Deviations.
1. HIGHER MENTAL FUNCTION: ABCD MMR/MMM (HUTCHISON)
a. Appearance Behavior and Communicational (All subjective)/ consciousness (GCS/TPP
b. Delusions and Hallucinations (from history itself you will have an idea.
c. Emotion (Pt sleeping pattern, enjoys life).
d. Memory:
1. Short term Memory
- Repeat 7 digits forwards and 5 digits backwards (Impaired Korsakoffs and alzheimer).In Macleods immediate memory is assessed the same way and if pt recalls 5 or less it indicates impairment, and short term memory is assessed by name and address test).
2. Recent Memory
- Who is the prime minister? Day of the week ? Day of the month?
3. Long term memory
- History itself will give a clue, when did he get married? When did she deliver?
e. Mental Tests
- Reasoning 100 -7, 20 -3
- judgement,
∙ House on fire what will you do?
∙ You find a letter on the road what will you do?
f. Mental Reflexes
- Glabella lap
Sharp fingers tap the Galbella (fingers kept above the field of vision) from back the back normally ellcits only 2-3 blinks before this reflex is inhibited.
- Grasping (frontal lobe disease).
2. Speech and language
∙ Mention about the handedness of the patient. In 90% of right handers and 60% of left handers Aphasia occurs only after lesions of the left hemisphere - Harrison.
a. Dysarthria (Difficulty in Articulation)
Ask the pt to say 'patakapataka' or fasxafasxa'
1. Cerebellar say'Sagarmatha' pt will say sa -ga - r - ma - tha (rhi - noc - er-os)
2. Pseudobulbar (spastic) say ' pashupathinath' pt will way pazhupazinaths (birzh conshishustion), associated with UMN lesions.
3. Bulbar due to lower motor neuron lesion can occur in MG also, there is also assiociation with dysphagia (Dysphagia also in Pseudobulbar) and regargiatation.
4. Cortical (not common at all)
5. Monotonous speech in parkinsonism (Kundu).
b. Aphasia
Disturbance of the ability to use language whether in speaking, writing or comprehension..
∙ Sensory, Receptive/ Wernickes 22/Fluent - Defect, in Parietal and /Or temporal.
Ask the pt to write his name Overwrite
Tell pt to raise hand.
∙ Motor/Broclas 44 - 45/ Non fluent - Defect in lower precentral gyrus
Pt won't speak much only yes and No. can't name simple things like pen, pencil
∙ Conduction Aphasia due to damage to arcuate fasciculus.Pt cannot repeat words.
∙ Global Aphasia
Both Wernickes and Brochas effected.
But in Hutchison given differently (see below)
Seven components (JPA ward question) AFCDRLE (Hutchison)
i. A - Articulation -ask pt say“Pashupathinath”.
ii. F - Fluency - best assessed in spontaneous conversation (depends on volume, phrase length > 3, melody - Harrison).
iii. C-Verbal Comrenhension ."Can a dog fly?", Where is the source of illumlantion in this room?". Harrison.
iv. D-Disturbance in naming. A deficit of naming (anomia) isthe single most common finding in aphasic patients. Name common objects (pencil or wristwatch), the patient may fall to come up with the appropriate word, may provide a description of the object ("the thing for writing "), or may come up with the wrong word (paraphasia) - Harrison.
v. R-Disturbance in Repetition -ask the pt to repeat "today is Wednesday", 2nd, of Jestha and this is the Teaching Hospital"-Hutchion
vi. L - Disturbance in reading - Obey simple written commands without reading out aloud like "touch your nose with your left hand"
vii. E - Disturbance in writing.
a. Ask pt to write his name
b. Ask for a written reply to a simple question like "Whats your address"
viii. Dysphonia (optional not in Hutchison's)
Difficulty in producing voice e.g. vocal card palsy.
3. Apraxia (Damage to Parietal Lobe)
- Inability to perform certain acts or movementss even through there is not sensory defect, weakness or ataxia, ask pt to light a box of matches, comb hair and write with pen.
2 types.
a. Ideomotor
In which concept is present but motor programme for usage is not accessible, the pt can ??? how he is going to do it but he can't do it physically (most common type)
b. Ideational
Pt has no concept, ask to pick up the pen and write and pt will from the other side.
Ask pt to light a match stick. If pt can't light (ideational )ask him to explain how he would have done it, if he can explain this it is ideomotor.
4. Cranial Nerve Examinaiton
1. Olfactory
- Inspect Nasal cavity bilaterally for patency & discharge
- First explain the procedure to the pt. and let him smell the three items. Use soatp, toothpaste .
- arlic (ideally it is Clove oil, Peppermint oil, Asafedida)
- Close eyes and one nosrill, and introduce each item at a time.
- Anosmia in sinusltis, trauma, meningitis, Subfrontal Meningioma.
2. Optic
a. Check Visual acvity byasking the patient to read something on the other side of the ward, you can also use the Counting fingers test, then hand movements last use perception to light.
- Also test for near vision (use glasses in near and far)
(Idealy snellen's chart and jeggers charts should be used.)
b. Visual Field- Confrontation test, stand 1m away, same level of pt first from side then move from inferior and superior. (Ideal is perimetry)
c. Colour vision
Use pen, shirt etc, ideal is isihara's chart. Mosst common is red (JKS)
d. fundoscopy - Not done.
3. III, IV, VI (LR6, SO4, R3)
a. Check for e xtra - ocular movement in H shaped pattern (ask about diolopia during movements)
b. Look for otosis (eyelid normal position
c. Nystagmus best assessed at < 30° (ENT- Rakesh Sir) (Please note that due to , visual loss, metabolic (CNII), Myasthenia gravis(CNIII), and labyrinthine dysfunciton (CN VIII) nystagmus can occur but since it's easy to elicit while examining ocular movements we have put nystagmus examination under III CN but anyways its optional).
d. Pupils
a. Round regular size 3 -4 mm
b. Reaction
- Light reflex
- consensual light reflex
- Swinging light reflex (Optic atophy)
- Accomodation (ask abt diplopia also)
Tell pt to look at a far object then bring an object close to his nose and ask him to look at the object, eyes will concerge,lens will accomodate and pupils will constrict. (Lost in Neuropathy.
5. Trigeminal
a. Check sensation forehead, cheek and mandible for sensory, light touch, cold and pinprick.
∙ Compare both sides
b. Clench teeth and feel over masseter and temporalis then tell pt to move jaw sideways against resistance and ask pt to open and close the mouth against resistance for pterygoids and Masster
c. Corneal reflex.
Ask pt to look up and opposite side, touch the lateral edge of the cornea (Limbus), iwht a light whip of cotton. Steady your handf by resting your little finger on the pt cheek. Pt will blink, watch both eye blinking (for consensual ) Easier method is to lightly blow air into pt. eye.
d. Jaw reflex - Tab with a knee hammer with the mouth slightly open just above the mentum. (Place your finger there & then tap) if the mouth slightly open just above the mentum. (place your finger there & then tap) if the mouth closes - Exaggerated responses.
7. Facial
a. An2/3rd tongue-' Check by Sugar, Salt, Lemon, Metro, Make 4 pieces of pape saving "guliyo", "Nunilo", "Amilo", "Titho", Then after putting swab on ant 2/3rd of tongue while the tongue is outside ask him to point at the respective card without drawing the tongue inside the mouth. Use diff swabs for diff soluiton. And ask to gargle after each test. If illiterate use colours.
b. Motor
Insepect the face, look at the expression, Nasolabial fold, frowining, drooling
Tell pt to look at finger while the finger is above is eyebrows to look at frowing.
Close eyes try to open against resistance. (Orbicular's oculli).
Ask pt to whistle (Buccinators), pull of out cheeks and test muscle power, Clench to see pplatysma, Smile to look for defiation (Orbicularis oris)
8. Vestibualr cochlear
Normal25dB - WHO (40 do in Hutichison)
Tick Watch test
- Whispering test, at 6cm then at 15cm if no reponse normal voice at 60cm (Hutchison)
- Then do Rinne and Webber Tests.
Nystagmus best assessed at 30 degrees (ENT - Rakesh Sir) optional
Vestibular function:Positonal vertigo, caloric test (Cows).
9. Glossopharyngeal
Sensory from post 1/3 of tongue (taste), posterior pharynx, Afferent for the gag reflex,
10. Vagus
Tickle the back ofthe phgarynx and note if palate moves up, (palatal r eflex)( Or else you can ask the pt to say"Aaah". Palatoal arches should move up equally or pulled to the affected side?
Give pt water to drink and see if there is require complete closure of nasopharynx - egg sounds like eng. Rub becomes rum. Listen for hoarseness of the voice and check Gag reflex.
11 .Accessory
Power of Trapezius from the back (elevate shoulders against resistance) and test power of SCM from front. (Move neck side ways & downward againsy resistance.
12. Hypoglossal
First inspect the tongue inside the oral cavity to look for wasting and fasciculation.
Protrude tongue it will diviate to the paralyzed side.
Tell pt to push cheeks from inside with the tongue against resistance from outside.
Bilateral fasciculations is pathognomic of Amylotrophic lateral Sclerosis.
5. Motor Examination
1. Bulk of the muscle and palpate it
Look for symmetry fasclculations, wasting look for abnormal movements and then measure the circumference. (Select 2 arbitrary bony points & look where the maximum bulk is and measure) look and feel over all the major muscles
2. Tone of the Muscle
Handle the limbs and move them passively over their various joints. (wrist, elbow, knee) .
After this lift the limb and leave, check the response against gravity also you can roll the limb to and fro to check for tonicity (Posting )
Can be Hypertonic or Hypotonic.
Hypertonic is of two types.
a. Spasticity - claso knife rigidity (Due to CST lesions)
b. Rigidity (Due to lesions extra - pyramidal system - basal ganglia
i. Cogweel type (parkinsonism)seen in wrist.
ii. Lead pipe seen in elbow.
iii. Gegenhalten (literally means go -sto) a plastic type of rigidity in which the resistance developed to passive movement is uniform during all phases of applied movement (VIVA -JPA -24th batch)
iv. Hysterical - the increase to passive movement increase in proportion to the effort applied by the exminer.
v. Dystonla (optional)
3. Power / Strength (Know MRC Grading)
After Inital assessment test against resistance, and always keep hand/finger over the bulk of muscle being tested. When presenting say you checked over all major joints)
-Lower limb (Ankle, Knee, Hip).
-Upper limb (Wrist, Elbow, Shoulder -in Shoulder1th 30 is carried out by supraspinatus and the next 60 by deltoid.
Trunk.
a. Beevor's sign for abdominal weakness
Pt. attempts to lift up the head from pillow againsy resistance, with paralysis of the lower segment the umbilicus movies upwards, and if it is upper vice versa (Babinsky Rising up sign - get thept to sit up without using hands, in spastic paralysis of a leg the affected limb will rise first but in hysterical paralysis this doesnot occur (posting question)
b. Diaphragm - important.
Ask the patient to take a deep breath and to 20 with a single breath. (Test for it in GBS, Myasthenia gravis)
4. Refles (grading , reassure, expose, tap tendon not belly, always stand on theright side).
Deep: (test both sides sequentiallY)
a. Ankle(S1, S2)
Ankle everted slightly dorsl - flexed (slightly flex at knee joint first)
2. Knee (L2, L3, L4)
Always reveal the quadriceps muscle and watch for any fasciculations. If reflex absent do the lendrassik's manoeuver, this increses excitability of ant horn cell and increases sensivity of muscle spindle. Tell the patient to perform the manoeuver jsut before you elicit the reflex as it lasts for only one second (Kundu).
Your can also pt to clench teeth, but this is only for upper limb (posting)
3. Supinator (C5, C6)
Elbow slightly flexed are pronated, contraction in brachioradialls (as this muscle was pereviously called supinator longus this relfex is known as supinator jerk - Sailesh and Kundu).
Inversion for the reflex: With lesions at the level of the supinator or biceps jerk, jerk may be lost but brisk flexion of the fingers seen.
4. Biceps (C5, C6)
Flex elbow in right angles and forearm in a semipronated position, 'Put finger'
5. Triceps (C6, C7)
Flex the elbow and allow the forearm to rest across the pt chest, tap above olecranon, and not over the belly of the muscle.
6. Hoffmans sign
Flicking of nail downwards cause flexion of thumb (deep hyperreflexia - optional)
If reflexes are exaggerated test for clonus (Ankle and Patellar) by bending the knee slightly and support it with one hand, grasp the forepart of the foot with other and suddenly dorsiflex this results in brief contraction followed by relaxation. The patellar clonus is exmined with index finger and thumb. Patellar is pulled upwards with a fold of skin behind the palm now sharp sudden displacement of this patellar downwards will produces a series of quadriceps contraction. (KUNDU)
Superficial
1. The plantar Reflex L5, S1) - (JPA Posting, remember L5)
The pt ankle is held by the hand and the outer margin to the 2nd meetatarsus is scratched with hammer,key (preferable - JPA method) stop stimulating as soon as you get the first movement of the great toe - JPA and KUNDU)
Normal Movement is:
a. Contraction of the tensor fascla lata, adductors of thigh
b. Flexion of the four outer toes followed by flexion of all toes
c. Ankle plantar flexedc and inverted.
Babinskl's extensor response:
1. Dorsiflexion of the great toe precedes all other movement.
- Fanning and extension of the other toes
- Dorsiflexion of ankle and flexion of hip and knee.
In Major CST lesions the receptive field of the extensor reflex enlarges so the reflex may be elicited using different techniques (Posting question including the reason)
a. Oppenheim's sign- Press heavily against Inner border of tibia (with index & thumb)
b. Gordon's reflex- Squeezing calf muscle or Achilles tendon (in Hutchison only Achilles tendon is squeezed and calf muscle squeezing has no name)
c. Chaddock sign
just swipe the lateral part of the foot in the dorsal aspect (Dr.Bikram)
Strike the skin around lateral malleolus in a circular fashion. (Kundu)
d. Bing(Pricking dorsum of foot), Moniz (Forceful passive plantar flexion). In amputation contraction of tensor fascia lata is seen as part of extensor response -Brissaud's sign (JPA)
2. Superfical abdominal reflex (T7 to T12)
- Form outer aspect to inner (lost in UMN)
- The reflex below were taught and elicited by Oil sir.
3. Anal (S3, S4)
- stroke, scratch skin near anus - contraction
4. Cremasteric (L1, L2)
- Stroke inner thigh - testicle moves up
5. Co -ordination of Movement
Before Ataxia can be ascribed solely to cerebellar disease it is important to ascertain if joint position sense is impaired or not. Even proximal muscle weakness can imitate ataxia.
Upper limb (Always both sides)
a. Finger nose test then ask pt to close eyes and do the same thing, In sensory ataxia (Post column) it will be more deranged.
b. Dysdladochokinesis (Cerebellar lesion)
c. Watch the patients dressing and underssing handling a book, picking up pins
d. Rebound phenomena (Posting)
Lower limb
a. Heel Shin Ankle test
b. Romberg's sign
Test for positional sense, feet together arms outstreched initially with eyes open then closed, if pt sways intially with eyes open can be Cerebellar, Labrythine or post column lesion. But, if pt sways more or even falls when he closes his eyes (romberg's sign positive) it's most probably due to posterior column lesion. It may be due to Labrynthine lesions but this is associated with positonal Nystagmus. (Hutchison).
c. Walking include tandem gait, in ataxia pt will deviate towards towards affected side (but asses this in gait it self).
6. Gait
Legs should be well exposed, feet should be bare, ask the pt to walk up the room turn around and come back, then ask the pt to walk in a straight line (tandem gait). (if pt ataxic walk with the pt - JPA) (Types of gait - JPA Posting) the first 7 written below are form Hutchison.
i. spastic Gait/Hemiplegic Gait- Narrow base, drags feet, difficulty in bending knee, circumduction of leg.
ii. Stamping Gait- In sensory ataxia, raises foot high, jerks it forwards and brings it down with a stamp
iii. High stepping Gait- In Common Peroneal Nerve palsy, to avoid toes catching the ground
iv. Drunken Gait - Cerebellar ataxia walks with broad base, placed irregularly.
v. Festinant Gait
In Parkinsonism, bent forwards, rapid short, shuffing steps, arms don't swing and presence of retropulsion (Niranjan sir)
vi. Marche a petipas- Frontal white matter disease, rapid steps
vii. Wadding Gait/Duck Gait- In Myopathies ( Dysthrophy)body tilted backwards, increased Lumbar Lordosis, feet planted widely apart, and body sways from side to side.
viii. Scissor Gait- Patient stands with cross legs each leg is advanced slowly and stiffly with restricted motion at the knee and hip. He steps one limb in front of the other in a semi circular fashion. Occurs in spastic paraplegia or bilateral hemiplegia. (KUNDU).
7. Involuntary Movements:
i. Chorea (BRJ Never Repeats in Postings ) -Viva
- Brief, Rapied , Jerky, Non Rhythmical, Involuntary, Purposeless.
ii. 2. Tremor (voluntary or Involuntary)-
- Rhythmic oscillation of any body part, keep paper over hands.
iii. Myoclonus (epllepsy)-Sudden,Brief (<100ms), shock -like, arrhythmic muscle twitches/lerking.
iv. Athetosis- VIVA in spinocerebellar disease, metabolic disorder, slow, distal, writhing, Involuntary distal movements
v. Asterexis - In Outrstretched hand and tongue.
6. Sensory Examiantion;
Proceed from abnormal to normal
1. Light touch (post column) with cotton, wool, symmetrical
C4/T2 - Junction of clavicle
C5 - Deltoid area
C7,C8 - Extends to elboe from hand mainly ventrally
L5 - Odrsum of foot
L4- Patellar and anteromedial shin
L2- Supero medial part of thigh
T12- Ingulneal Ligament
T10 - Umbllicus
T8 - Xiphisternum (Y7 - Dr. Bikram)
T6- Nipple (T4 - Dr. Bikram)
2. Discriminative with paper clip (post column) 2mm (5mm - Dr. Bikram) on fingertips, 1cm on toes.
3. Positional , explain to pt then closes eyes, only touch one finger, and move only one finger
4. Recognition of size, shape wt and form (lost in parletal)
Check each arm and leg spearately
Two sticks which one is longer?
Two objects which one is heavier?
Give coin and pen and ask to identify?
5. Vibration
First over the sernum and ask if pt can feel
it.
Then dorsum of Great toe, Lateral malleolus, Tibial shaft, Ant Sup illiac Spine, dorsum of stops and then examiner should feel the vibration to compare. If pt feels vibrations on the lower part no need to p roceed proximally (KUNDu ) post column lesions.
6. Temperature - cold with tuning fork and hot water get from nurse station.
7. Graphesthesia (Parletal lobe lesions ) - Posting
Pt unable to recognize alphabets and figures written on pt plam's when his eyes are closed.
8. Sensory inatention (Parletal lesion)
Ask pt to close his eyes, simultaneously stimulate homologus points on opposite sides of the body and ask the pt to indicate which side was touched. In sensory inattention the stimulus on the abnormal side is not preceived.
9. Pain
With pin compare both sides all dermatomes, and then squeeze the muscle mass to elicit deep (tabes dorsalis) pain.
7. Autonomic Nervous System
Bed side include: Light reflex and accommodation, dry skin, resting tachycardia, trophic changes on skin.
a. Postural Hypotension (in macleod's and Harrison it is a drop of > 20 SBP and drop of >10 in DBP) - at 3 min.
b. Deep Breath tests
Ptospine, count pulse, then count again telling pt to take 6 deep breaths in one minute, in Normal subjects the pulse should fail by >15 and in autonomic dysfunction it drops by <10
3. Handgrip test and valsalva manoeuver using sphygmomanometer.
8. Meningeal Irritation
a. Neck Rigidity
Ask pt to flex the neck as fully as possible to ascertain the degree of movement and then relax. Then passively flex the neck, this chin should normally touch the chest without pain. In rigidity flexion causes pain and movement is resistered by spasm.
b. Kernlg's sign
Pt supine, passively extend pt knee on either side when the hip is fully flexed, this causes pain spasum of the hamstrings.
c. Brudzink's sign
Elicited with the patient in the supine position and is positive when passive flexion of the neck results in spontaneous flexion of the hips and knees.
9. Nerve Root Entrapment (Optional But Can Be Done In Spinal Cord Disease)
a. Straight leg raising test
b. Trunk rotation and coughing.
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