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4. Posture: active
5. Look at the face No suffering features on the face
a. Head : shape and size are normal ( use finger tips to palpate the skull),no deformities, no scar, no
tremor/ shaking ( de musset sign)
Nose: form is normal and symmetrical, no deviation of septum, no participation of wings in breathing, no
herpes nasalis ( see nostril..inside-pathology in syphilis, AIDS, lobar pneumonia)
Eyes: place symmetrically, no exophtalmus, enopthalmus
a.Lids: no edema, no ptosis, no stenberg sign ( rare blinking of eye)
b.Sclera: no jaundice, no hemorrhages
c.Conjunctiva: no pallor, no petechiae,no pinguincular
d.Cornea: no scars, no ulceration,
e. iris :no arcus senilis, no Fesir fleshner ring ( green ring in Wilsons disease, liver cirrhosis)
f. pupils : size and shape are symmetrical
test :
1. Murbers sign/ convergence : pen move toward to the nose ( normally eyes will move toward the nose,
while in thyrotoxicosis eyes will move to somewhere else)
2. Nystagmus : pen move to left, right, up, down , observe any jerking movement of eyes
3. Strabismus : focus on the pen at 1 side and ask pt to close one eye( alternately both eyes, if prescence
of deviation when open the closed eye, it may be the lesion of oculomotor nerve)
4. lid lag : pen slight moving downward w/o moving the head ( it is positive when prescence of white
sclera)
Conclusion: horner syndrome negative ( no exopthalmus, ptosis, myosis), normal convergence, lig lag
negative., no nystagmus, no strabismus
Lips : pinkish, no herpes, no scars, no fissures
Ears : place symmetrically, no tophi, no deformities
6. Neck : cylindrical shape, size ( no enlarge)no swelling, no visible pulsation of neck vessels , thyroid gl
is unpalpable ( 4 methods) , no stock collar ( swelling of neck-due to obstruction of sup v.c )
a. stand in front : use thumb to palpate ask ask pt to swallow
: isthmus: central part of neck, near intersternum
lobes : lateral part of isthmus
b. stand bhind ( use fingers)
7. Skin : Color of the skin ( check sclera, conjunctiva, oral cavity included tongue and soft palate, palm)
is normal for his race, presence of libido recticularis on hands ( cyanosis wf white spots), absence of
anemia, jaundice, hyperkeratinosis, central n peripheral cyanosis, mucous membrane are pinkish.
Skin is moist , not rough, texture not oily( use dorsal part of hand to slide over pts trunk, extremities, n
back). And painless ( palpate) Skin is elastic ( making fold at dorsal part of the hand, wrist ).
Nails: configuration is normal. No brittleness, no lesion, no strips, thickness 1mm
Hair: masculine, even distribution, No baldness. No brittleness, not easy loosing n break. No grey hair, no
oily ( check armpit hair )
8, Subcutaneous fat: well developed and symmetrical ,no places of the best deposit of fat- 16mm female,
12.5mm male ( make a small fold below costal arch horizontal fold, at biceps-lateral, under scapula-
horizontal fold), no subcutaneous emphysema( ant n post) , no edema ( check face, upper and lower
extremities ,sternum, sacral part)
9.Lymphatic system : Skin above the projection of lymph nodes ( occipital, periauricular, anterior ears,
parotid, submandibular, sublingual , neck ant , post, btwn leg of SCM , supraclavicular, infraclavicular,
armpit ( left hand to left hand), epitrochlar, popliteal) are normal. Temperature above the lymph nodes are
normal, no hyperemia
-Submandibular LN is palpable . it is single, at each side, mobile, painless, soft elastic consistency, size 1-
0.5cm, not connected to surrounding tissue.
10. Musculation : muscular sys is well developed and symmetrical , tension is normal-palpate everywhere(
no stiffness , no increase and decrease of muscle tone) , palpation of muscle is painless, no convulsion , no
tremor ( raise hands wf separate fingers), no asterixis ( raise hand and 90 degree of wrist ), strength of the
muscle is well developed and symmetrical , (doc cross his hand, and ask pt to use his strength to grab my
finger OR hold the pts biceps / wrist, ask pt to resist my strength) Scale for grading muscle strength is 5
Scale for grading muscle strength ( 0-5)
1.no muscle contraction detected
2. a barely detectable flicker or trace of contraction
3. active mov of body wf gravity eliminated
4. active mov against gravity
5.active mov against full resistant w/o evidence of fatigue. This is normal muscle strength
11.Bone: well developed, symmetrical, curvatures at left and right distal phalanx little fingers, no
deformities, no shortening, no tenderness, no periostitis , no ostalgia( palpate everywhere) percussion
( clavicle, sternum, ribs, radial, elbow, styloid, femoral, tibial)are painless.
12. Spinal column : shape is normal, no pathological curvature ( incline forward, ), no deformities,
palpation of paravertebral (pt incline forward, palpate wf two fingers , along the paravetebral line frm
cervical to lumbar), percussion of vertebra is painless, movement of spinal column is full volume,
active, w/o pain and crepitation ( stand, w/o flex knee, bend forward and backward, side)
- slight scloriosis at chest region
-shobers sign positive ( line btwn 2 post iliac crest, perpendicular to the line 10cm upward, 5cm
downward-N change more than 4cm)
13.Joints : form and size are normal, no skin changes, no swelling, and no color changes on the joint,
temperature above joints is normal, palpation of joints( shoulder, elbow, wrist , interphalax, knee, hip,
ankle) is painless, no fluctuation
1. Bulge sign : minor effusion : LH fixate, RH push down
2. BAllon sign : major effusion : RH medial, LH push at laterally
3. Balloting sign: large effusion: both thumb fixate at patella and push to feel resistance crackles, mov is
active, no tenderness in mov, vol of mov is active w/o pain
-no crackles ( move the hands and listen), active and tender in mov, change mobility of joints
Form of chest is cylindrical. Anterior-posterior and lateral ratio is 2/3, epigastric angle is 90, ludovici
angle is moderately pronounced, shoulder neck angle 110, scapular is moderately compact to the chest,
direction of ribs in lateral sides are oblique ( both sides , rise hand and put at the occipital part),supra n
infraclavicular fossa are moderately pronounced, ICS are not widen, no intrusion , no
protrusion( emphysema),
Lettons sign negative( presence of mov of ICS), chest is not symmetry, right part is greater than left part
of the chest.( assessment of shoulders level ant and post, clavicle scapula , measure at nipple both side), no
deformation at sternum, no additional muscles taking part in breathing, equality of expansion ( pt breath
and see clavicle)
Palpation of chest
1. palpation of trachea : position of trachea is at the midline of neck , no deviation 1,2,3 finger tech
( jugular, midline up), trachea tug ( use thumb and index fixate-emphysema, hydrothorax)
3. Chest rigidity / elasticity is normal :ant-post, lat , R L ( FINGER CLOSE TOGETHER, and 90)
4. chest circumference : quite: 85 deep inhale 88, deep exhale:83 : resp excursion is norm ( post-
scapular angle, ant nipple)
5. equality expansion is symmetrical ( forefinger under scapular angle or ant/ post : 10th rib)
Percussion
1. comparative percussion ( loud)
- During comparative percussion anteriorly on the .line, clear lung resonance sound is
detected and symmetrical.)
- During comparative percussion posteriorly, clear lung resonance sound is detected and
symmetrical: 2 percussion above the scapular, ask patient to cross his hand 4 percussion at the
interscapular part, nearer to the scapula, and 4 percussion below the scapular (altogether 10 points)
- acc to line,
Parasternal line Start frm 1st -4th ICS ( 4x) Start frm 1st 2nd ICS ( 2x)
Mid-clavicular line Start frm 1st -5th ICS ( 5x) Start frm 1st 2nd ICS ( 2x)
Anterior axillary line Start frm 3rd -6th ICS ( 4x) Start frm 3rd -5th ICS ( 4x)
Mid axillary line Start frm 3rd -7th ICS ( 5x) Start frm 3rd -5th ICS ( 5x)
Posterior axillary line Start frm 3rd -8th ICS ( 6x) Start frm 3rd -5th ICS ( 6x)
2. Topographic percussion
a. Apex (ant: pt sit, turn head during percussion , moderate percussion frm midclavicular to mastoid,
post : head bend)
- Upper border of the right lung anteriorly is determined at 3cm (normal 2.5-3) above the clavicle
( NB: rmbr to report CENTIMETER)
- Upper border of left lung anteriorly is determined at 3cm above the clavicle.
- Upper border of lungs posteriorly ( BOTH SIDE) are determined at level of spinous proc of 7th
cervical vertebra with 3cm distance frm lateral C7
b. Kronigs isthmus is detected at right lung with 6cm , left lung with 5.5cm ( N:5-8cm )-light
percussion
c.Lower border of the (left/right)lungs on (line) is determined at ( light percussion)- frm 2nd ICS
percuss till dullness
Mid- 23 23 46 - - -
clavicular
line
Mid-axillary 34 34 68 34 34 68
line
Scapular 23 23 46 23 23 4-6
line
e. Traubes space
1. along 10th rib percuss up , till dullness, n percuss down till dullness
2. alone midclavicular line, percuss finger by finger till dullness
Auscultation
1. Normal vesicular breathing sound is detected ( under clavicle,
2. egophony : absent ( auscultateask pt to say ee ( bcome ay if presence of consolidation)
3. broncophony is normal. ( auscultate .. ask pt to say 44/ sh )
Cardiovascular System
1.Region of heart
Inspection :No cardiac humpback. No visible apex beat, Cardiac beat, aortic pulsation, pulmonary trunk
pulsation, left ventricular aneurysm (postinfarction cardial aneurysm).
Palpation
Apex beat is palpable at 5th ICS, 1.5cm medially from left midclavicular line with its width 2cm2 . The
amplitude, strength and resistance are moderate , duration is unsustained. ( NB: COVER THE NIPPLE)
Cardiac beat is not detected( vertical palm at 4th-5th ICS) . There is no abnormal pulsation of aorta ( palm
at right 2nd ICS near sternum) and pulmonary trunk ( palm at left 2nd ICS near sternum). Left ventricular
aneurysm is not detected ( fingers at 3rd-4th ICS)
Thrills
1. same as auscultation points
2.Systolic (palm at manubrium sterni )and presystlic thrill( palm at 4th -5th ICS) are not detected.
3. systolic thrill ( compare aorta n pulmo), diastolic ( compare epi n aorta)how to differentiate systolic n
diastolic thrills?? By palapte carotid artery simultaneously wf thrill b4 pulsation is diastolic, after
pulsation is ystolic
**pericardial region : apexcardiacsystolic thrill ( compare aorta and pulmo ) LV aneurysm
Differential features between carotid artery pulse & jugular vein pulse
Carotid artery pulsation Jugular vein pulsation
Seen internal to the sternomastoid muscle Seen in the triangle formed by the 2 heads of the
sternomastoid and the clavicle
Better palpable Better visible
Carotid artery pulsation Jugular vein pulsation
Predominant outward movement Predominant inward movements
One peak per heart beat 2 peaks per heart beat
Carotid artery pulsation Jugular vein pulsation
Not variation with posture and respiration Variation with posture, respiration, abdominal
compression
Not obliterate Obliterate
Carotid artery pulsation Jugular vein pulsation
Level of pulsation unchanged by position Level of pulsation changes with position dropping
as the patient becomes more upright
Level of pulsation not affected by inspiration Level of pulsation usually descends with inspiration
Carotid artery pulsation Jugular vein pulsation
Pulsation not eliminated by pressure on the point Pulsation eliminated by light pressure on the vein
just above the sternal end and clavicle just above the sternal end of clavicle
3.Epigastric region
Inspection
No visible epigastric pulsation, no visible pulsation of abdominal aorta (in upright and lying position,
during inspiration and exhalation).
Palpation of epigastric pulsations
Right ventricle, aorta or liver pulsation are not palpable , No true and transmitted liver pulsation: direction
of pulsation (upward-transmitted, downward-true), location of index and middle fingers of right hand on
the anterior surface of the liver widening of the distance between fingers- true pulsation, unchanged
distance- transmitted pulsation)
Hepatojugular reflux (Plesh sign negative): pts head turn to one side, abdomen relax, ask pt to inhale and
push under rib cage, inspect jugular vein for at least 5-7sec)
Pulsation of temporal( unsually we are NOT going to palpate), carotid, subclavian( unsually we are NOT
going to palpate), brachial, femoral, popliteal, dorsalis pedis, posterior tibial artery are palpable
Left border of relative cardiac dullness is detected in 5th ICS , 1.5cm medially frm the left midclavicular
line ( percuss frm ant axillary line , along the cuvature of the rib, vertical hand position, till dullness)
Upper border of relative cardiac dullness is detected at upper edge of 3rd rib ( percuss little by little along
the line 1cm laterally frm left sternum edge( not acc to ICS) till dullness)
Transverse diameter of the heart (N=3-4cm on the right ,N= 8-9cm on the left, total=11-13cm).
for absolute: find relative border 1st shift the hand frm the point 1cm laterally ( DEMONSTRATE
OBVIOUSLY coz teachers are blind) percuss wf superlight percussion till absolute dullness)
Right border of absolute cardiac dullness is detected at left edge sternum at 4th ICS
Left border of absolute cardiac dullness is detected in 5th ICS , 2cm medially frm the left midclavicular
line
Upper border of absolute cardiac dullness is detected on 4th rib
Auscultation of vessels:
Absent of duroziers double murmur ( auscultate femoral artery)
Absent of Double trouble tone(auscultate femoral artery with pressure on it)
Absent of Nuns murmur (venous hum in the neck)- auscultate above the midpoint of clavicle near neck,
pt turn head to left
GIT
1. inspection
a. oral cavity : absence of smell, no carosis, no peridontitis, no artificial teeth, all teeth are present
(N=32)
b. gums : pinkish in color, no bleeding , no ulceration , no suppuration , no grey edge
c. Mucous mbrane of hard and soft palate is pinkish, no pigmentation, no ulceration, no cicatrices, no
cleft, no scar
d. Tougue : color is pinkish, moist , clean, no ulceration , no scars, no difficulty to put out the tongue
frm the mouth, no deviation during it, no enlarge, no hyperplasia
e. Mucous membrane of throat is pinkish color, moist and smooth
f. Tonsil: not enlarge, pinkish color, no pus lacume
g. Abdomen: size not enlarge, flat configuration, no navicular abdomen, no diverticulum, no
pendulum abdomen, no frog belly, symmetry, no visible peristalsis of stomach and intestine, no
region of pigmnetation, no scars, no stria, no dilation of subcutaneous network, linea alba and
umbilical orifice are in satisfactory condition ( ask pt to rise a bit)
Cullen sign negative: ecchymoses at umbilical and paraumbilical area ( acute pancreatitis, ectopic
rupture during pregnancy)
Sister Mary John : nodules ( mts of stomach carcinoma)
2. palpation
FIRST OF ALL, ASK ANY PAIN AT THE ABDOMEN
-pt position : semiflex of legs, hand at the side
1. During superficial palpation, abdomen is soft, painless, no local tension., no tenderness of
abdominal muscle
-method 1 : 10 points ( press the abdomen)
-method 2 : ivashkin tech ( 9 points)
** Hippocrates method : 1 hand located under rib cage, 1 hand press alone the line 1cm frm linea alba(
similar to succusion ( N=splashing sound) method but w/o drinking water, to check peptic ulcer) N=
no splashing sound
9. greater curvature of stomach is palpable: find lower border 1st greater curvature (wf slight
oblique hand position, inhale push up to make fold, exhale slide down)
10. pancreas is not palpable : : find lower border 1st move 2cm upward inhale push up to make
fold, exhale slide down)
11. Pyloric region : find lower border 1st alone the level of lower border 45 degree up, hand position
perpendicular to it inhale push upward make fold exhale slide down : is painless and has
pencil-like in structure, hard in consistency and is 2 cm in size
12. colon (NB! After palpate , rmbr to ask DO U FEEL PAIN?? ) 4 steps : position of hand( NO
KNUCKLES)inhale and push upward to make foldexhale push deeplyend of exhale: drag
downward
a. sigmoid (left) : detected at the border of mediolateral 3rd of left umbilical-iliac line, painless, soft,
smooth, cylindrical, 2.5cm, mobility 2cm, no rumbling
b. caecum ( right ) : detected at the border of mediolateral 3rd of right umbilical-iliac line, painless,
soft, smooth, cylindrical, 2.5cm, mobility 2cm, rumbling
c. ascending ( left hand at the lumbar region, finger toward vertebra( PUCH UP WHEN EXHALE) ,
right hand direction as left hand ) :painless, firm inconsistency, smooth, cylindrical, 2.5cm,
mobility 2cm, no rumbling
d. descending: (left hand at the lumbar region, finger toward vertebra( PUCH UP WHEN EXHALE) ,
right hand oppo direction to left hand) : painless, firm in consistency, smooth, cylindrical, 2.5cm,
mobility 2cm, no rumbling
e. transverse: ( find lower border if stomach 1st) : it is detected at 2cm below the lower border of
stomach , painless, hard in consistency, smooth, cylindrical, 2.5cm, mobility 3cm, no rumbling
f. Ileum ( near ceacum, more horizontal): painless, soft, smooth, cylindrical, 2.5cm, mobility 1cm,
rumbling
HEPATOBILIRARY
LIVER
1. Percussion:
Determination of the lower border of liver by percussion along the mid clavicular line.(light percussion)
2. Palpation of the lower border of liver- percuss to find lower border 1sthand position: left hand hold
the rib cage, right hand at the lower border of the liver wf middle finger flexBreath in: make skin fold
(pull to our direction) - breath out: push deeplybreath in: hand forward
-liver is not palpable.
GALL BLADDER
1.Kers sign ( R)
By using thumb, press the point of projection of gall bladder, ask patient to inhale.
Intensified pain during inhalation = positive
5.Murphy sign ( R)
Same as Kers sign but doc is behind the patient, use 4 fingers of right hand to palpate.
Balloting liver- monkey hand at RH, LH not involved, like strining w/o removing the hand frm abdomen
SLEEN
1.Inspection:
No protrusion, no scar, no enlargement of abdomen in left hypochondrium region.
2.Percussion:
Vertical size: possible use midaxilllary line or oblique line 4cm laterally from the sternoclavicle junction
and free edge of ribs from up to down and from down to up. (N= 4-6cm)
Horizontal line:
From umbilical to rib cage (10th rib) till dull sound, along the 10th rib from posterior till dullness. (N=6-
8cm)
3. palpation: percussion frm umbilical toward 10th rib at 30degree n palpate : same as liver
GENITOURINARY SYS
1. inspection :No swelling, no hyperemia, no protrusion on lumbar and suprapubic region.
3.Percussion:
Pasternatskys symptom: pain in percussion in lumber region(kidney)
URINARY BLADDER
As patient to urinate first.
From umbilical, percuss till dullness (usually at pubic symphysis).
At this point, palpate urinary bladder (same method as palpation of intestine).