Basic of Clinical Examination for OSCE

Basic of Clinical

Examination for

1) Cardiovascular system

a. Physical examinations b. Blood pressures c. JVP and it’s concept d. Peripheral vascular disease e. ECG* and murmurs 2) Respiratory system

a. Physical examinations b. Peak flow meter 3) Hematological system a. Cervical / Neck b. Axillary c. Inguinal 4) Gastrointestinal system a. Abdominal examination b. Fluid thrill & shifting dullness

c. Examination for hepatosplenomegaly d. Per rectum

1) Endocrine system a. Diabetes

b. Thyroid gland (hyper & hypo thyroidism) 2) Reproductive system

a. Breast examination

b. Pelvic examination (PAP smear) c. Gestational examination

3) Renal system

4) Musculoskeletal system a. Shoulder

b. Hip

c. Spine (plus neck)

Semester III

5) Nervous system a. Motor b. Sensory c. Cranial nerves

H

ISTORY

T

AKING

Personal details

1) Name 2) Age 3) Address 4) Occupation* 5) Religion / race 6) Marital status

Past medical history

1) Hospitalization a. Year

b. Reason for admission c. Diagnosis

d. Where / medical center e. Duration of stay f. Treatment 2) Surgery

a. Diagnosis / reason for surgery

b. Year

c. Where / medical center d. Treatment

3) Long standing illness a. Year & how long b. Diagnosis c. treatment 4) Allergy a. Type of allergy i. Drugs ii. Food iii. Animal iv. Others

b. What happens when in contact (reaction) with the allergens

Social history

1) Smoking

a. How many per day b. How long the patient

have been smoking 2) Alcohol

a. Type of alcohol b. How much

c. How long has the patient been drinking 3) Home a. Type of housing b. Environment 4) Work a. Working environment b. Stress levels at work 5) Diet

a. Meal habits b. Type of food 6) Hobbies

a. Exercise

b. Any other activities

Family history

1) Must cover 3 generation a. Parents b. Siblings c. Wife/husband d. Children 2) If alive a. Age b. Major illness 3) If passed away a. When b. Why Always follow sequence

1-Personal details 2-Presenting complaints 3-Past medical history 4-Social history

5-Family history 6-Drugs history

*always use open ended questions **systemic history for SEM 5

History of

presenting illness

(HOPI)

GENERAL I. Onset

II. Site / character

III. Aggravating / relieving factors IV. Timing – progression, duration,

time of the day V. Severity

VI. Associated symptoms

VII. What have you done about it? VIII. medication

Pain (chest / abdomen) =SOCRATES 1) Site 2) Onset 3) Character 4) Radiation/spread 5) Associated symptoms 6) Timing 7) Elevating/relieving factor 8) Severity

*further explanation will be at The 15 wisdom of Dr. Htin Aung >>>

Shortness of breath (SOB) 1) Onset

2) Duration 3) Progression

4) Aggravating / relieving 5) Severity? Affecting sleep? 6) Associated symptoms Cough

1) Productive/non productive 2) Intermittent / continuous 3) Time of the day

4) Blood 5) Severity

6) Aggravating / relieving factors 7) Progression 8) Associated symptoms Sputum 1) Amount 2) Volume 3) Color 4) Smell 5) Consistency 6) Blood Stool / Vomitus 1) Amount 2) Volume 3) Color 4) Blood 5) Smell 6) Consistency Constipation 1. Frequency

2. Feeling of incomplete evacuation 3. Consistency of feaces

4. Acute / chronic

5. Associated symptoms – pain, bleeding.

6. Time spent straining 7. Stool?

8. Aggravating / relieving factors Diarrhea

1. Everything about stool, especially on consistency 2. Frequency

3. Urgency of defecation 4. Abdominal pain

5. Aggravating / relieving factors 6. Severity

Dysphagia

1. Liquid / solid 2. Painful

3. Regurgitates? Into nose? 4. Where (specific location) the

The History “THY FORMAT”

– from Dr. Htin Aung

1) Site : site of pain 2) Duration :

a. /12 (month) b. /7 (days) c. /24 (hours) d. /60 (minutes)

3) Onset : rate of s/s comes / spread a. Sudden: - vascular - injury - mechanical b. Slowly : - infection - metabolic - endocrine 4) Triggers : what cause the pain

5) Progression: getting worse, comparing workload.

6) Timing : intermittent / continuous (if intermittent, ask how long the pain last and how long rest needed)

7) Character : a. Stabbing b. Crushing c. Gripping

d. Shooting ; e.g. headache

e. Sharp tearing ; inflamed, sliding, pleurae, two surface sticking f. Burning pain ; chemicals (gastric acid in the esophagus) g. Cramping

h. Colliding ; GIT, colon, esophagus, urinary tract i. Dull aching ; organs with coverings

8) Frequency

 How often?  Increase lately?  Time of the day?  Etc

9) Severity : mild / dull  B/D o NE  B/D o E

 B/D o R

 B/D o less exertion than normal IHD Breathlessness Dyspnoea On Exertion/Non-exertion/Resting MI: >10min AP: 5-10min

10) Spread : 11) Implication: a. Weight b. Work c. Appetite d. Sleep e. Micturation f. Bowel 12) Aggravating factor 13) Relieving factor 14) Seen other doctors 15) Associated symptoms

IHD

- neck, jaw, left arm

- nerve cardiac plexus C4-T1

CVS

RESPIRATORY

Complaint: Chest tightness SOB: Dyspnoea, Orthopnea, Paroxysmal Nocturnal Dyspnoea, Palpitation, Chest pain.

Heart failure: ankle edema, Cough, SOB PAD / PVD Intermittent claudication (claudication distance for PAD)

Epistaxis, hemoptysis, SOB, cough, sputum color

Asthma, Smoking

Wheezing due to narrowed airway DD for Supra-clavicular swelling Metastasis: solid, hard, fixed Infection: warm, tender Lymphoma: firm

1. Rheumatic fever

Sore throat (relapsing RF)

Fever, sweat ,chills ( exposure to rain) Relieve: panadol

Worries: excessive sweating, embarrassing history of RF, check family

1. TB:

Productive cough, high fever with night sweats, wt loss, lymphadenopathy, decrease appetite

Investigation: AFB culture, CXR, Mantoux

2. IHD (Angina Pectoris)

Pain: Location, Radiation, Duration, Exertion, Frequency, Progression, Severity, Precipitating Factors

Risk: F/H, Diet (hi salt / fat), exercise, stress, smoke and alcohol. E.g.:

2. Pneumonia SOB

Sputum: color, consistency, volume, blood, frothy

Relieve, aggravator

Investigation: Sputum culture, PBS.

X-ray

Heart (boot shaped) Tetralogy of Fallot Cardiophrenic angle

Costophrenic angle

Kerley B line (heart failure) Air fluid level (pleural effusion) Pneumoconiosis

TB coin lesion, consolidation and cavitation Renal IVP - hydroureter, calculi

Fracture - colles (radial bone), dinner fork Osteoarthritis - osteophyte

Osteosarcoma - sunburst Rheumatoid arthritis - Pannus

Past 3mth Past 1wk

Severity Can do work Crushing, limited activities Frequency Twice a wk everyday Precipitating

factors Carry >20kg Carry >5kg climb 3 stairs

3. Peripheral Arterial Disease (PAD) Pain and cramp at unilateral limb Aggravate: walking claudication dist Relieve: sit down, rest

F/H of arterial disease: HT, Heart attack

Worry: unable to move leg anymore Systemic review: over wt

Actions: Low fatty diet, light exercise, decrease smoke and wt

Not PVD as PVD has edema, warm, and pain anytime.

GY

Bleeding disorder Haemophilia A/ B

Malabsorption/Gastrectomy: IDA Vegetarian/ Pernicious anemia: B 12 def Folate: no vegetables, pregnant

Iron: Vegetables and liver and meat Malaria

Hodgkin lymphoma: Reedsternberg cell (owl's eye)

1. Peptic ulcer (benign)

Clinical indication: Pain aggravate by eating (Gastric Ulcer) Relieve by eating (Duodenal Ulcer)

Relieve: Biscuits, Antacid

Aggravate: hard liquor, smoking, stress, NSAIDs

Assoc symptoms: dyspepsia, vomiting, nausea, diarrhea, melena, blood in vomit F/H

1. Hemophilia A / B (A more common) -X-link recessive

Pain of knee, swelling, hemoarthroses Significant Past medical history Profuse bleeding on tooth extraction, wound Hemoarthoses, hematoma, bruise

PT, BT norm, APTT prolonged F8/F9 assay

F8/9 concentrate

3 Cx of ulcer

Perforation => peritonitis

Bleeding of stomach => hemorrhage Cancer

2. Hernia

Occupation: wt lifter, pregnant

Sign: swelling in left groin, size, pain, radiation

Aggravate: wt lifting, standing up, cough Relieving: lie down

Risk factor, chronic coughing, constipation, obesity

2. Lymphoma with metastases to bone Pain in left leg

Other: swelling of painful leg, swelling n lump at groin area, Polyuria, Polydipsia

(due to Na, Hypercalcemia, Sugar in DM) F/H Leukemia

Ix: BM aspiration, BM trephine biopsy, Serology

3. Cholecystitis

Aggravate: Fatty food, egg

Associated symptoms: nausea, burping, indigestion, fever, diarrhea, vomiting

3. Haemolytic Anemia with pneumonia Yellow eye (pre-hepatic jaundice) Cough, with bloody, yellowish phlegm

Aggravate by cold relieve cough syrup and antibiotic,

Assoc symptoms: fever, muscle ache, tiredness, SOB

Causative organism atypical mycoplasma pneumonia

Ix: Sputum culture, PBS, Coombs test, serology. Test for blirubin

4. Colorectal Cancer:

Wt loss, appetite, bowel habits, nature of stool, strain and pain (tenesmus)

What he done, laxative (useful?)

Risk factor: F/H altered bowel habits, wt loss, age

Left side: Constipation, blood in stool Right: IDA, diarrhea, melena

5. Diarrhea

Food poisoning Melena / hematemesis Hernia (Inguinal (direct/indirect), umbilical. etc)

Environment clean food / water supply Palpable LN: question to ask

How long? Lump changed size? Painful? Lost wt? Generally well?

ENDOCRINE

RENAL

1. Hypothyroid

Afraid of cold, gain wt, depression, croaky voice (hoarseness),

menorrhagia Aggravating for hoarseness: sour food

Myxoedema (legs fatter)

Common cause: iodine deficiency, Hashimoto's thyroiditis

Urination (further refer to paper)  When's last time

 when started, for how long  Frequency

 Nocturia (Sleep Disturbed)

 Quantity (normal – l500ml, Polyuria, Oliguria <500m1; Anuria negligible)  Retention, Hesitancy

 Incontinence (Urge. Stress-cough, sneeze, laugh)

 Pain? (Dysuria, Strangury, Renal colic) Radiation?

 Color (tea colored blood-hematuria)  Smell ( pungent- ammoniacal) Males:

Hesitancy, Post Micturation dribbling, incontinence, sexual function, impotence, Urgency (BPH)

Females:

Stress incontinence

Menstrual and obstetric History Sexual Function=> UTI, dyspareunia Systemic:

Headache / fever (UTI)

Sleep disturbance due to nocturnal Work condition (with lack of water) Renal Calculi -

Eg. Drink too much mineral water as work require on the go. Pain from loin to groin, hi uric acid level. Hematuria.

Prostate Problem that caused the urgency. IX: FBC, UFEME, X-ray KUB, Ultrasound. IVP Urine sample: Casts, Crystals, Pyuria, and Protein.

Uraemia

Weakness, lethargy, oedema, proteinuria, HT, uraemic frost.

2. Hyperthyroid

Intolerant of heat, lost of wt, increase appetite, irritable, tearful

Palpitations, Diarrhea, amenorrhoea 3. Diabetes

Very thirsty, Polyuria, polydipsia, nocturia (disturbed sleep)

Diminished sensation (numbness), muscle wasting, vaginal discharge ( immunosuppressive - candida) diabetic retinopathy (blurred vision), nephropathy metformin / insulin (injection or oral or both)

Inquire more on drugs, compliance, and latest blood glucose level and check up. F/H

Pregnant mother: big babies 4. Cushing

Truncal obesity, thin skin, bruising, pink/purple striae, HT, Proximal muscle weakness

5. Acromegaly (pit adenoma)

Complaint: headache, vision affected, bitemporal hemianopia

Change in appearance: big hands / feet / macroglossia, oily skin, dentures not fitting. excessive sweating

+ve symptoms: visual deterioration (double vision)

6. Prolactinoma

Complaint: white watery discharge from breasts

Assoc symptoms: headache; irregular period, amenorrhea.

Ix: MRI, CT scan of pit gland, Serum PRL level

Menarche ( primary amenorrhea) Cycles, days, heaviest on when Regular/Irregular (can predict?) Flow (no of pads/soak/half soak)

-menorrhagia, oligomenorrhea clots, spotting Pain - Dysmenorrhea e.g. endometriosis Associated Symptoms: Nausea, vomiting, headache, diarrhea, water retention, pelvic congestion, breast tender and swelling Tx: Diuretics (congestion),

NSAIDS(mediators), diazepam(nerve)

ED: duration. onset, progress, severity, freq,

- Implication: depress, suspicion, stress/affect at work, wife, sad, frustration,

- His own remedy: Viagra, porn,

- Risk: HT, diabetes, psychology, drugs(b-blocker, Heart disease), SID,

- Ask about size, swelling of scrotum/penis if present.

- Other symptoms swelling of legs, fatigue, weakness, anemia

SEXUAL HX

- Dyspareunia e.g. endometriosis - Itchy (pruritus), Rash, Discharge

- Blood: menstruation, miscarriage, cancer, cervical erosion/polyps

- Purulent: Vaginitis, cervicitis, endometritis, retained tampon

T.vaginalis: frothy, watery, pale, yellow white

discharge

Candida (white thrush): thick cheesy, with

excoriations and pruritus Case:

Leucorrhea, foul smelling, pruritis, embarrassing

Associated symptoms: burning urination, fever, dyspareunia, dysuria, spotting, lower abdominal pain.

- Infertility (PRL), Lower abdominal pain ( PID, ectopic pregnancy)

- Sexual activity, Contraception

- Approach: explain, confidentiality, Have Boyfriend before? Husband? Are u very close/intimate with him/her? Is it a sexual relationship? Sexually active? Is it protected? What type of protection? All the time? If not, r u sure he his your only partner?

Man: Penis discharge, ulcer Non painful

(syphilis) burning sensation urinating (gonorrhea)

OBSTETR1C HX - "I think I'm pregnant!"

l. Amenorrhea: LMP, EDD

Sickness (nausea/vomiting) marked at 12-21 wks, maybe precipitated by strong odors. So don't get near

2. Sickness (nausea/vomiting) Marked at 12-21

wks

3. Breast:

Breast tenderness (tingling-frank pain) Engorgement

Enlargement of Montgomery's tubercles (6-8wks of gestation)

Colostrum at 16th wk

4. Quickening (1st _{perception of fetal}

movements)18-20 wks in primigravidas, 1 mth earlier in multiparas

5. Urinary

Frequency (norm 3-5/day and 1/night) Nocturia, as increase intra-abdominal pressure

Mom:

- How many children their gender, birth wt, breast feed? Complications of pregnancy. Need to know each & every one.

- Antenatal care booking;

4 wks =0-32 wks 2 wks = 32-36wks Weekly after that

- Problems with pregnancy

- Color coding: red, yellow, green, white - Diet (Ca, Fe, Folate)

- Health (DM, HT, preeclampsia) *glycosuria; SBP>30; DBP >15 - Fetal movement. Abortion/Full term - Delivery types- vaginal/caesarian /assisted - Complications

- Health of Baby, antenatal/postnatal - Immunization of baby/mother HIV, Hep B - Eg.G3P2Al.

● Age: ElderlyOA YoungRheumatoid, Ankylosing Spondylitis ● Gender: M AS, F RA ● Onset/Duration: Suddendisc prolapsed

Acuteacute osteomyelitis, septic arthritis SA

InsidiousOA, AS, RA ● Site:

Large wt bearing joint(hip/knee)OA Small joint (wrist, MP, PIP)  RA Low backOA, AS Sacro-Illiac joint AS Big ToeGout ● Progression, Swelling (infection/inflammation) ● Symmetrical involvementRA ● Radiation: hip-knee. Sciatica-post

thigh ● Char:

ThrobbingSA, AOM, acute hemathrosis, Dull acheOA, RA Shooting sciaticaPID

Night criesTB, malignant tumor (due to release of protective muscular spasm at night)

● Painkiller, Frequency ● Severity:

Very severePID, AOM, SA, Gout Mild to moderateRA, OA

● Early Morning Stiffness: RA>30min

OA no EMS or relieve by movement ● Deformities:

Advanced RA (swan neck)

Advanced OA, AS (bamboo spine) ● Giving Away: knee, due to

weight-bearing, cartilage damage or muscular weak (polio)

● Systemic Features:

FeverRA, AOM,SA,SLE RashSLE

Wt gain, fever, weakness, fatigue ● Occupation:

Manual workerOA

Maid's Anee, carpet worker’s knee (Bursitis)

● Sexual exposure (gonorrhea,syphilis) ● F/HHemophilia (hemoarthroses),

gout, TB, RA Cases

Osteoarthritis: Wt bearing joint, Elderly, Insidious onset, dull ache, morning stiffness less than 30min. History of trauma over wt. Aggravate by walking, squatting, relieve by painkiller and rest

Malignancy: Pain (night cries)

associated symptoms: stiffness, swollen Appetite decrease, lost of wt,

Risk factor: smoking, HT, Diabetes, Sedentary lifestyle, over wt. Metastatic normally to spine (breast Ca)

CNS

Pain: common

Characteristic ,severity, site, onset, duration, temporal relationship, factors Headache, back pain, facial pain Numbness

Special symptoms  Fits, faints turns

 Dizziness & vertigo (cerebellar)  Altered vision, hearing and smell

(CN)

 Difficult in walking  Incontinence

 Loss of memory and intellect (dementia)

 Altered speech Cases:

1. Fits

◘ When, where, frequency ◘ Events leading to attacks of

convulsion: sleep deprivation, stress, fever, exhaustion, alcohol

◘ Symptoms of aura with duration: hallucination, “dejavu” (feel like experiencing 2nd time) .

◘ Features: tongue biting,

incontinence, cyanosis, excessive salivation, aura, hallucination, jerking of limbs, loss of consciousness, how long ◘ How he knows? Who else is

around?

◘ Post-ictal symptoms & duration: Drowsiness, lethargic, tired for several hrs.

◘ Diurnal variation?

◘ Hobbies: Mt climbing, swimming, speed sports.( dangerous)

2. DM:

◘ Peripheral neuropathy ◘ S/S Tingling n numbness ◘ Slipping out a slippers ◘ Autonomic neuropathy(GI)

Indigestion, decrease peristalsis, bloating, vomiting after meals, diarrhea and constipation intersperse ◘ Gangrene, amputation,

◘ Other clinical symptoms: retinopathy, CHD nephropathy

3. Transient ischemic Attack (TlA) ◘ Headache

◘ Char: Pounding/Throbbing ◘ Frequency/Duration/Site. ◘ Symptoms preceding attack:

Dizziness, nausea, visual disturbance (ischemia of ophthalmic artery during TIA)

◘ Associated symptoms: Nausea, lethargic, weakness, vomiting, disturbed vision

◘ Precipitating factors: stress (work, single), cheese, bright light, before menstruation

◘ Relieving factors: ponstan, sleep in dark

◘ F/H 4. SOL

◘ Complaint: Left weakness 1 month, numbness 1 week, left vision field affected 3 days

◘ One sided heavy headache - 1 month ◘ Social: Smoke, Drink

◘ Mental Behaviour changes: ◘ Forgetful, short tempered

◘ Dx: Slowly growing space occupying lesion, brain tumor, Toxoplasma

gondii, Hydratid, Amoeboid Cyst

5. Strokes

Assoc with atherosclerosis, HT, Slurred speech, hemiplegia

Cardiovascular

System

Checklist

Headings Action

1. Introduce

2. Permission 1. Put the bed into 45° angle 2. Wash hands

3. Adequate exposure 3. General

Inspection 1. Name, age, gender, racial_{2. Conscious} 3. Alert

4. Communicative

5. Well built – not chacectic 6. No general discoloration 7. No respiratory distress 8. Not in obvious pain 9. No gadget attached

4. Hands 1. Color

(Cyanosis, Jaundice, Pallor) 2. Temperature 3. Moisture 4. Capillary refill 5. Clubbing 6. Splinter hemorrhage 7. Xanthomata

8. Osler’s nodes (pain) 9. Janeway lesion

5. Pulse 1. Radial 2. Brachial 3. Carotid 4. Femoral 5. Popliteal 6. Posterior tibialis 7. Dorsalis pedis Comment on:

1. Rate (for 1min, unless told) 2. Rhythm (R, RI, II)

3. Strength 4. Symmetry (radio-radial, radio-femoral) 5. Character 6. BP See behind 7. Face Eyes: 1- sclera (yellowish) 2- conjunctiva (pallor) 3- corneal archus 4- xanthelasma Mouth: - oral hygiene

Headings Action 8. Neck (JVP) 1. Inspection 2. Measurement of JVP height 3. Hepatojugular reflux 9. Precordium Inspection 1. Size 2. Shape 3. Symmetry 4. Scars 5. Deformity (excavatum, carinatum, kyphosis, scoliosis) 6. Visible pulsation (especially at the apex region)

Palpation 1. Apex beat (comment!) 2. Parasternal heave 3. Thrill over the 4 region

-mitral -tricuspid -aortic -pulmonary

Auscultation Auscultation over the 4 region for* 1. S1 & s2 2. Added sound 3. Murmurs 10. Pitting edema

11. Thanks Always remember to thank the patient SIGNS/EXAMINATIONS SIGNIFICANCE IN T R O

Greet, Introduce, Explain, Permission (GIEP)

 Wash & Warm hands.  45 degrees

 Adequate exposure

G

E Age, gender, ethnic group, height,

N E R A L IN S P E C T IO N

average weight. He is conscious, alert, and co-operative. He is not in any respiratory distress, no general discoloration and he is not in obvious pain. Respiratory distress:

1. Tachypnoea

2. Use of accessory muscle

3. Flaring of nostrils (ala-nasi movement) 4. Stridor/wheezing 5. Cyanosis Mention: (1) conscious (2) alert (3) co-operative (4) no respiratory distress (5) not in obvious pain (6) no general discoloration H A N D S

(1) Moisture & Temperature Hypercapnea

(2) Color (normal = pinkish) (a) cyanosis (blue)

(b) jaundice (yellow) (c) pallor

(a) Peripheral deoxygenating

Cyanosis = blue discoloration of the skin and mucous membrane, due to presence of deoxygenated Hb in blood vessels (>50mg/L) *does not occur in anemia

*central cyanosis in congenital heart disease (b) Right heart Failure

(c) Anemia

(3) Clubbing

5 stages of clubbing:

(a) Increase nail fold fluctuation (b) Loss of nail bed angle (c) Increased Curvature (d) Drumstick shape (e) Pain

= increase in angle between proximal nail and nail Seen in:

Cyanotic Congenital Heart Disease Infective Endocarditis

(4) Capillary refill (Normal < 2s)

Press for at least 10s. Impaired blood circulation e.g. atherosclerosis

(5) Splinter Hemorrhage = linear hemorrhages lying parallel to the long axis of nail -Talley. Vasculitis of nail bed caused by IE

(6) Osler's Nodes

= red, raised tender nodules on pulps of the fingers (or toes) or on the thenar or hypothenar eminences Seen in IE

(7) Janeway Lesion = non tender, erythematous maculopapular lesions containing bacteria which occur rarely on the palms or pulps of the fingers in patient with IE

(8) Tendon Xanthomata

=yellow or orange deposits of lipid in the tendons that occur in Type II hyperlipidaemia.

P

U

L

S

E

(1) Rate (normal 60-90 bpm)  Tachycardia (>100bpm)  Bradycardia (<60bpm)

(2) Rhythm Arrhythmia

(3) Volume

(4) Symmetry (delay)

Types: radio-radial, radio-femoral Seen in

 Atherosclerosis  Coarctation of aorta

 Aortic (abdominal) aneurysm

E

Y

E

S

(1) Sclera - Jaundice Right Heart Failure (2) Conjunctiva – Pallor Anemia

(3) Corneal Archus Hypercholesterolemia

(4) Xanthelasma Hypercholesterolemia M O U T H Oral hygiene

Post streptococcal infection and dental caries related to IE or rheumatic heart disease

N

E

C

K

JVP**see more behind Mainly for RHF causing congestive hepatomegaly

1. inspection & location 2. measurement

3. character

-hepatojugular reflux -visible non palpable -dual pulsation C H E S T INSPECTION (1) Surgical scar (2) Visible pulsation (3) Deformities (pectus

excavatum and pectus carinatum)

Excavatum = inwards Carinatum = outwards PALPATION (*Warm hands first!)

(1) Locate Apex Beat

Don't lie about it. If can't find. say so. After locating it count the ribs and report the location.

Always report the location in relation to midclavicular line. (E.g. 3cm medials to MCL or 2 cm lateral to MCL). If the

(1) Displaced Apex beat (a) Chest deformities

(b)Secondary to pleural effusion, pneumothorax.

(c) Left ventricular dilatation IF NOT PALPABLE

examiner marks the particular point, and it is near axilla, report according to axillary lines.

(b) Hyperinflation of lung (asthma or emphysema) (c) Pericardial Effusion

(2) Parasternal Heave This is at LEFT parasternal border. Ask the pt to breathe in and out then hold the breath after expiration then use your hand to find any heave.

(3) Thrills at the 4 region Report the anatomical location

Thrills= palpable murmurs

Mitral - 5th _{ICS at mid clavicular line}

Tricuspid - 4th _{ICS at left parasternal border}

Pulmonary – 2nd _{ICS left parasternal border}

Aortic – 2nd _{ICS right parasternal border}

AUSCULTATION ** see more behind

Auscultate the 4 areas. You MUST use both diaphragm and bell

Bell ~ emphasize low pitched sounds such as murmur of mitral stenosis

Diaphragm~ for high pitch sounds. It filters the low pitched sounds. To show that you know how to differentiate systolic and diastolic murmur you have to auscultate and

feel for the carotid pulse at the same time. Causes of murmur (1) Stenosis (2) Murmur (3) Anemia / thyrotoxicosis (4) IE

(5) Congenital heart disease

If murmur coincides with carotid pulse then it's systolic murmur.

Otherwise it's diastolic murmur. Report on:

4. S1 & S2

5. Additional heart sound 6. murmurs

L

E

G Pitting pedal edema Press at bony prominences (At least 15s)

Reason: Congestive Heart Failure, Constrictive pericarditis

1. GIEP

2. PREPARATIONS

(a) Ask patient (i) Smoking

(ii) Caffeinated drinks

(iii) Enough rest! Enough sleep! Exercised before coming in (b) Make sure patient free of clothing's

(c) Inspect the arm (i) Arterial-Venous fistula for dialysis (ii) Scar

(d) Palpate the brachial artery

(e) Position arm so that the brachial artery in antecubital crease at the level of the heart.

3. BLOOD PRESSURE CUFF

(a) Length of inflatable bladder should be 80% of upper arm circumference (b) Width of inflatable bladder should be 40% of upper arm circumference

4. TECHNIQUE

(a) Place the inflatable bladder over the brachial artery 2.5 cm above antecubital creases. (b) Secure the cuff.

5. PALPATORY METHOD

(a) Estimate the systolic pressure with the radial pulse. (Inflate 10mmHg at a time)

Reason : (i) Use it as an estimation to prevent discomfort from unnecessary high cuff pressure.

(ii) To avoid auscultatory gap (a silent gap btw systolic & diastolic) (b) Deflate & wait for 15s to 30s.

6. AUSCULTATORY METHOD

(a) Place the stethoscope on brachial artery. (b) Inflate cuff rapidly.

(c) Deflate at 2-3 mmHg per second.

Systolic pressure → appearance of sound

Diastolic pressure → Total disappearance of the sound report to the nearest 2 mmHg.

KOROTKOFF SOUND'S (Sounds heard when auscultate over brachial artery) Phase 1 → 1st appearance of sound (SYSTOLIC PRESSURE)

Phase 2 & 3 → Increasing loud sounds Phase 4 → Abrupt muffling of sound

Phase 5 → Disappearance of sound. (DIASTOLIC PRESSURE)

*Phase 5 better estimate of diastolic pressure than phase 4 because it's less subjective and more correlated with the diastolic pressure.

2 Situations where give false reading -) (1) BP cuff is too small

(2) If the patient's elbow is not flexed.

Few steps on JVP examinations;

1) Position at 45 degrees and ensure the muscle is relaxed by asking the patient to look at the left.

2) Identify the double pulsation. It may be a bit difficult. Only report your findings. Use natural light.

3) Estimate the vertical height. The ruler on the sternal angle must be vertical to the ground (NOT TO THE PATIENT).

4) Then report the unit in cm of H20. A normal value is less than 4cm

of

H20.

Vein Internal jugular vein

Location Medial to sternocleidomastoid muscle

Enters neck through mastoid process, runs deep to sternocleidomastoid enters thorax between sternal & clavicular head

Wave form a-atrial systole c-ventricular systole

v- peak pressure in RA prior to opening of tricuspid valve Causes of

increase JVP

1. Heart failure particularly RHF 2. Pericardial effusion

3. SVC obstruction 4. Tricuspid stenosis

CAROTID ARTERY JVP

Single pulsation Double pulsation

Palpable Visible, but not palpable

Not Occludable Occludable

None Varies with respiration

None Varies with position

None Hepato-jugular reflux

Rapid outward movement Rapid inward movement

1. GIEP

2. INSPECTION (Common mistake) (a) Loss of hair

(b) Muscle wasting (c) Ulceration.

(d) Skin color (pallor / cyanosis) (e) Surgical scar

3. PALPATION - Before touching patient always ASK patient whether there is any pain or not. If yes and say, for an example, pain at right leg always starts with left leg.

Why must start with normal???

Reason: To have an idea on what is normal

Rule 1:

Vertical to floor and at sternal angle Rule 2:

Horizontal (parallel) to floor and at upper most visible JVP

PATIENT

Height to be measured

: The patient might have arterial disease on both legs.

How to palpate? It's use your back of your palm and start at the proximal part of the leg and slowly shift your hand downwards to the distal part.

Check for (a) Skin temperature (b) Tenderness (c) Dry skin

4. PERFUSION

(a) Capillary refill (b) Dorsalis pedis artery (c) Posterior tibial pulse (d) Popliteal pulse (e) Femoral pulse

1) Radial = lateral to bony part of radius

2) Brachial = medial to brachialis muscle tendon

3) Carotid = medial to

sternocleidomastoid muscle 4) Femoral = just below the inguinal

ligament, midway between ASIS and pubic symphysis

5) Popliteal = deep in the popliteal fossa at the back of the knee just medial to the midline

6) Posterior tibialis = bony groove behind the medial maleolus (2cm behind and below)

7) Dorsalis pedis = proximal end of 1st

Heart sounds

Additional sounds

Opening snap High pitched Diastolic Mitral stenosis Systolic ejection click Early systolic High pitched Aortic stenosis Pulmonary stenosis Non systolic ejection click High pitched Systolic Mitral valve prolapsed Sl M1+Tl Systole Loud-mitral stenosis Soft-mitral regurgitation S2 A2+P2 Diastole Loud A2-systemic hypertension

Soft A2-aortic stenosis + aortic regurgitation Loud P2-pulmonary hypertension S3 Gallop rhythm Low pitched, Mid diastolic Physiologic =pregnancy Pathologic=LVF, aortic regurgitation, mitral regurgitation S4

Higher pitched gallop Late diastolic

Physiological =NONE! Pathological

Murmurs

Central cyanosis Peripheral cyanosis

Tetralogy of Fallot (congenital heart disease) Obstruction of large vessels All parts of the bodies involved Mostly periphery

Signs of peripheral blood disease 1) No blood supply a. Cold b. Pale c. No sweat (dry) d. Hair loss 2) No nerve supply a. Numbness b. Tingling 3) No venous perfusion a. Edema b. Congestion / cyanosis Left heart failure

Diastolic Early diastolic Decrescendo Aortic regurgitation Pulmonary regurgitation Mid

1. dyspnoea 2. basal crepitation 3. cyanosis

Right heart failure *** 1. JVP elevated 2. edema

Respiratory

System

Headings Action

1. Introdu

ce

2. Permiss

ion

1. Put the bed into 45° angle 2. Wash hands

3. Adequate exposure 3.General

Inspection 1. Name, age, gender, racial 2. Conscious

3. Alert

4. Communicative

5. Well built – not chacectic 6. No general discoloration 7. No respiratory distress 8. Not in obvious pain 9. No gadget attached

4. Hands 1. Color

(Cyanosis, Jaundice, Pallor) 2. Temperature

3. Moisture 4. Capillary refill 5. Clubbing

6. Nicotine staining (NOT TAR!)

7. Thenar and hypothenar muscle wasting 8. Flapping tremors (asterixis)

5. Pulse Comment on:

1. Rate (for 1min, unless told) 2. Rhythm (R, RI, II)

3. Strength 4. Symmetry (radio-radial, radio-femoral) 5. Character 6. BP Mention only 7. Face Eyes: 1- sclera (yellowish) 2- conjunctiva (pallor) 3- Horner’s syndrome Nose: 1-blood 2-mucous or discharge 3-nasal polyps 4-engorged turbinate 5-deviated septum Headings Action Mouth: 1-oral hygiene 2- pharyngitis 3-tonsilitis 4-enlargment of tonsils 8. Neck (trachea) 1. Position -Trachea deviation 2. Movement-Tracheal tug 3. Length 4. Lymph nodes 9. Precordium Inspection 1. Size -AP diameter -Transverse diameter 2. Shape

3. Symmetry (shape & movement) -AP diameter -Transverse diameter 4. Scars 5. Deformity (excavatum, carinatum, kyphosis, scoliosis, flail chest) 6. Use of accessory muscle

for respiration (SCM) *some of us do respiratory rate

Palpation 1. Chest expansion 2. Tactile fremitus 3. Apex beat Percussion  Apical  Upper  Middle  Lower  Laterals (axilla)

Auscultation 1. Auscultation on deep breath in and out through mouth for

-Breath sound (N=Vesicular) -Intensity

-Added sound 2. Vocal resonance

3. Whispering pectoriloquy

IN

T

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O

Greet, Introduce, Explain, Permission (GIEP)

 Wash & Warm hands.  45 degrees / sitting down  Adequate exposure G E N E R A L IN S P E C T IO N

Age, gender, ethnic group, height, weight, built, nutrition

E.g. Mr. Chan is a middle aged Chinese man of average height and built. He is well nourished and of average weight. He is conscious, alert, and co-operative. He is not in any distress, no general discoloration and he is not in obvious pain. Note:

respiratory rate: normal <14/min

accessory muscle= sternocleidomastoid, platysma, strap muscle Mention: (1) conscious (2) alert (3) co-operative (4) no respiratory distress (5) not in obvious pain (6) no general discoloration H A N D S

(1) Moisture & Temperature Hypercapnea (2) Color (normal = pinkish)

(a) cyanosis (blue)

(b) jaundice (yellow) (c) pallor

(d) palmar erythema (e) nicotine staining

(a) Peripheral deoxygenating - V/Q imbalance

- pneumonia - COPD

- pulmonary embolism (b) cor-pulmonale

(c) anemia (chronic disease) (d) polycythemia

(e) chronic smoker

(3) Clubbing

(a) Cancer

(b) Lung Suppurative Disease - empyema

- Lung abscess - bronchiectasis (c) Fibrosing a1veo1itis

(4) Small Muscle Wasting in hand Pancoast tumor suppressing TI

(5) Tremors

(a) flapping tremors

(b) fine tremors

(a) Hypercapnia or hyperuremia due to heart failure, respi failure, liver failure, kidney failure or uremia

(b) Patient on Beta agonist

P U L S E (1) Rate (normal 60-90 bpm) (2) Rhythm (3) Volume (4) Symmetry (delay)  Tachycardia (>100bpm)  Bradycardia (<60bpm)

F A C E _EYES (1) Jaundice (2) Pallor (3) Homer's Syndrome Horner's Syndrome

(1) Constricted Pupils (miosis) (2) Drooping eyelids (partial ptosis) (3) Loss of sweating (anhydrosis) (4) Enophthalmus

*ALL IPSILATERAL and

DUE TO LOSS OF SYM FUNCTION NOSE

(1) Blood

(2) Sinus Discharge

(3) Septa Deviation (3) causing nasal obstruction

(4) Nasal Polyps (4) asthma

(5) Engorged Turbinate (5) allergic rhinitis or other allergic conditions MOUTH

(l) Oral Hygiene (1) bad oral hygiene predispose to pneumonia (2) Cyanosis

(3) Pharyngitis (3) = inflammation of pharynx. Due to URTI (4) Tonsilitis (enlarged tonsils) (4) = inflammation of tonsils. Due to URTI

N

E

C

K

(1) Position :- CHECK WITH MEDIASTINUM ALSO (1) Position (a)PUSH Pneumothorax Tumor Haemopneumothorax (b)PULL Lung fibrosis Lung Collapse (2) Length

From lower border of cricoid to suprasternal notch :

Must be at least 3 fingers

(2) length

Emphysema →Lung hyperinflation →Ribs UP→ Sternum up →So the length will be less than 3 fingers

(3) Movement – No Movement (No tracheal tug)

(3) Aneurysm of arch of aorta

(4) Lymph nodes (palpation) (4)Lung cancer

C H E S T INSPEECTION (1) Diameter (1) Diameter:  AP < transverse; Normal

 AP = transverse; barrel shape(hyperinflation)  AP > transverse; pigeon (hyperinflation,

asthma or emphysema) (2) Shape

a. Pectus Excavatum a. inward (funnel) due to reduce lung capacity b. Pectus carinatum b. outward bowing (pigeon); chronic childhood _{respiratory disease or rickets} C _{(3) Movement}

H

E

S

T

(a) A-P Expansion (PEN) Say: PRESENT, EQUAL NORMAL,

REDUCED EXPANSION VERY IMPORTANT!!! For both AP + Transverse in almost all lung

diseases

Unilateral: fibrosis, consolidation, collapse, pleural effusion, pneumothorax

Bilateral: COPD, diffuse pulmonary fibrosis (b) Transverse Expansion

(c) Flail Chest (c )Fracture segments of ribs at both ends (blunt injury)

(d) Paradoxical Breathing Decrease transverse expansion during inspiration

(d) Chronic Emphysema ribs become horizontal. So, when diaphragm contracts it pulls down ribs

(4) Skin a. scars

b. radiotherapy lesions PALPATION (**warm hands first!!)

(1) Chest Expansion Apex, middle, lower

SAY: Chest expansion present, normal and equal at both sides

Note: apex is for AP chest expansion

Reduction in: Lung collapse, Lung fibrosis, lung consolidation, atelectasis, COPD

(2) Vocal tactile fremitus Can you please say 99?

SAY : Tactile Fremitus present normal and equal at both sides. DON'T FORGET AXILLA

Increase in:

Lung consolidation, Lung Fibrosis, Tumor Decrease in :

Pneumothorax + lung collapse, hydrothorax

(3) Apex beat

(3) Apex beat

Towards: lower lobes collapsed, localized fibrosis Away : pleural effusion, tension pneumothorax Impalpable: hyperinflated 2ndary _{to COPD}

PERCUSSION (technique is important) Do at

1. apex, 2. on clavicle,

3. beneath clavicle, 2nd ₃rd ₄th ₅th

4. upper + middle + lower axilla SAY : Equal resonance on both sides of the lung fields

Note: try to estimate percussing at the apex, upper, middle and lower. Never forget the axilla!

Hyperresonance: Pneumothorax, Emphysema, COPD

Dull : Consolidation, atelectasis, collapse, tumor Stony dullness: pleural effusion, haemothorax, empyema, hydrothorax, chylothorax

AUSCULTATION

Similar place to that of percussion

SAY

(a) No diminished breath sound (b) No bronchial breath sound. (c) No added sound such as

crackles, wheezes & pleural friction rub

(d) Normal Vesicular breath sounds heard

(a) Consolidation (b) Peripheral tumor

(c) Just above pleural effusion line

Crackles ( non musical, louder at inspiration) (a) CONSOLIDATION

(b) COPD (c) TB cavity

Wheezing (musical and louder during expiration & due to narrowing of airway)

(a) Asthma (b) COPD Pleural rub

Inflamed pleura in thrombo-embolism, pneumonia, pulmonary Vasculitis

(2) Vocal Resonance (say 99) Results same with tactile vocal fremitus

(3) Whispering pectoriloquy (whisper 123)

TITLE INSPECTION TRACHEA & MEDIASTINA L SHIFT CHEST EXPANSION (PALPATION) TACTILE VOCAL

FREMITUS PERCUSSION AUSCULTATION

Pneumothorax

Reduced chest expansion at the affected site

Away from the

affected site Reduced on the affected site Reduced on the affected site

Hyperresonant on the affected site

Reduced breath sound on the affected site Pleural Effusion Reduced chest expansion on affected side Trachea shifted away

from the affected side Reduced on the affected site Reduced on the affected side Stony dullness on affected sides Reduced breath sounds on affected side Pleural Rub

Consolidation Reduced chest expansion on affected side

No trachea shift Reduced on the affected site Increased on the affected side Dullness on affected sides Reduced breath sounds on affected side Bronchial breathing Crepitations Lung collapse Reduced chest expansion on affected side Trachea shifted towards the affected side Reduced on the affected site Reduced on the affected side Dullness on affected sides Reduced breath sounds on affected side Lung Fibrosis Reduced chest expansion on affected side Trachea shift towards the affected site Reduced on the affected site Reduced on the affected site Dullness on affected side Reduced breath sounds on affected side

Emphysema Reduced BOTH _sides No trachea shift _{Reduced length} Reduced BOTH _sides Reduced BOTH _sides

Hyper resonant or

normal BOTH sides

Reduced breath sounds both sides

Asthma Reduced BOTH

sides No trachea shift

Reduced BOTH

sides Normal Hyper resonant

Prolonged expiration Wheezes

Abnormal pattern of breathing: Type of breathing.

Types Causes 1 Sleep apnea-cessation of airflow for more than 10 seconds

more than 10 times a night during sleep

Obstructive (e.g. obesity with upper airway narrowing, enlarged tonsils, pharyngeal soft tissue changes in acromegaly or hypothyroidism) 2 Cheyne-Stokes' breathing - periods

of apnea (associated with reduced level of consciousness) alternate with periods of hyperpnoea (lasts 30 s on average and is associated with agitation).

This is due to a delay in the medullary chemoreceptor response to blood gas changes

Left ventricular failure

Brain damage (e.g. trauma, cerebral hemorrhage) High altitude

3 Kussmaul's breathing (air hunger)deep, rapid respiration due to stimulation of the respiratory centre

Metabolic acidosis (e.g. diabetes mellitus, chronic renal failure) 4 Hyperventilation, which results in alkalosis and tetany Anxiety

5 Ataxic (Biott) breathing-irregular in timing and depth Brainstem damage 6 Apneustic breathing-

inspiratory pause in breathing

Brain (pontine) damage

7 Paradoxical respiration - the abdomen sucks inwards with

inspiration (it normally pouches outwards due to diaphragmatic descent)

Diaphragmatic paralysis

Wheezing = continuous musical breath sound = inspiratory wheeze; COPD

Crackles = interrupted, non musical breath sound = peripheral airways collapsed on expiration Stridor = rasping or coaching noise, loudest on inspiration

Haematological

System

IN

T

R

O

Greet, Introduce, Explain, Permission (GIEP)

 Wash & Warm hands.

 Lying down on bed with 1 pillow /  Sitting down on a chair

 Adequate exposure G E N E R A L IN S P E C T IO N

Age, gender, ethnic group, height, weight, built, nutrition

1. Racial origin => Thalassaemia 2. Pallor =>Anemia 3. Bruising =>Platelet disorder 4. Jaundice =>Hemolytic anemia 5. Scratch marks =>Pruritis =>Lymphoma =>Myloproliferative disorder 1. Racial origin 2. Pallor 3. Bruising 4. Jaundice 5. Scratch marks H A N D S 1. Koilonychias

=dry, brittle, ridged, spoon-shaped nails

2. Pallor (nail bed) 3. Digital infarction 4. Palmar creases pallor 5. Gouty arthritis 6. Pulse - tachycardia

7. Purpura, petechiae, ecchymoses

1. Koilonychias

=>dry, brittle, ridged, spoon-shaped nails =>Fe deficiency anemia

=>Fungal infections => Raynaud's phenomenon

2. Pallor (nail bed)

=>Anemia

3. Digital infarction

=>Abnormal globulin (cryoglobulinamia)

4. Palmar creases pallor

=>Anemia 5. Gouty arthritis: Felty's Syndrome 1. Thrombocytopenia 2. Hemolytic anemia 3. Myeloproliferative disease 4. Skin pigmentation 5. Leg ulceration 6. Hemophilia 6. Pulse - tachycardia =>Anemia

7. Purpura, petechiae, ecchymoses

=>Thrombocytopenia or platelet dysfunction =>Coagulation disorder =>Systemic vasculitis T H E F O R E A R M S Hess test

 BP cuff on upper arm  Inflated to 10 mmHg above diastole  5min  Deflate  Petechiae (+) =>Thrombocytopenia =>Capillary fragility

T H E F A C E

1. Hair - grey hair & blue eyes

2. Eyes - jaundice & conjunctiva pallor 3. Mouth Gum hypertrophy Atrophic glossitis Waldayer' s ring ~Monocytic leukemia ~Megaloblastic anemia ~NHL A X IL L A R Y N O D E S 1. Apex/central

2. Lateral (above & lateral) 3. Pectoral (medial) 4. Infraclavicular 5. Subscapular C E R V IC A L & S U P R A C L A V IC U L A R N O D E S (N E C K ) 1. Submental 2. Submandibular 3. Jugular chain 4. Posterior triangle 5. Supraclavicular 6. Preauricle 7. Postauricle 8. Occipital 1. Site (position/extent)

Localized = Local infection, early lymphoma

Generalized = Late lymphoma 2. Size: normal=<lcm

3. Color/temperature 4. Pain & tenderness

Pain = Infections or acute inflammation

Painless = Lymphoma

5. Consistency Hard = Carcinoma

Soft/rubbery = Lymphoma 6. Surface texture / overlying skin

Inflamed = Infection Tethering = Carcinoma 7. Fixation Fixed = Carcinoma G en er ali ze d L ym ph ad en op at h y 1. Lymphoma 2. Leukemia(ALL/CLL) 3. Infection (viral/protozoa) 4. Drugs 5. Infiltration (sarcoid) 6. Connective tissue disease

(RA/ SLE) L oc ali ze L ym ph ad en op at h y

1. Local acute or chronic infection 2. Carcinoma metastases

Gastrointestinal

System

Headings Action 1. Introdu ce GIEP 2. Permiss ion

1. Lying flat with one pillow 2. Wash hands

3.General Inspection

1. Name, age, gender, racial 2. Conscious

3. Alert

4. Communicative

5. Well built – not chacectic 6. No general discoloration 7. No respiratory distress 8. Not in obvious pain

9. No gadget attached

4. Hands

(i) Color - jaundice, cyanosis, pallor, palmar erythema (ii) Leuconychia (iii) Clubbing (iv) Koilonychia

(v) Small Muscle wasting (vi) Dupuytren's contracture (vii) Tremor : Flapping

* remember positive sign first (color, moisture & temperature)

5. Arms

(i) Spider naevi (ii) Scratch mark (iii)Bruising /petechiae/

ecchymoses / purpura (iv) Axillary hair

6. BP Mention only 7. Face Eyes: 1- sclera (jaundice) 2- conjunctiva (pallor) 3- corneal archus 4- xanthelasma Mouth: (i) Hydration (ii) Jaundice (iii) Fetor hepaticus (iv) Angular stomatitis (v) Glossitis

(vi) Oral hygiene (vii) leucoplakia 8. Chest (i) spider naevi

(ii) gynecomastia

9. Abdomen

Inspection (a) Size & shape (b) Symmetry (c) Deformity (b) Umbilicus (c) Movement with respiration (d) Scar (e) Striae (f) Dilated veins (g) Obvious peristalsis (h) Visible pulsation

(i) Obvious masses

Palpation 1. Light palpation 2. Deep palpation 3. Systemic palpation 4. Liver

5. Spleen

Percussion  General percussion  Liver span

 Spleen (plus Traube’s space)

 Shifting dullness  Fluid thrill Auscultation 1. Bowel sound

2. Bruit (aortic & renal) 11. Thanks Always remember to thank

IN

T

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Greet, Introduce, Explain, Permission (GIEP)

 Wash & Warm hands.

 POSITION: FLAT with one pillow

 Adequate exposure G E N E R A L IN S P E C T IO N

Age, gender, ethnic group, height, weight, built, nutrition

Mention:

(1) conscious (2) alert

(3) co-operative

(4) no respiratory distress (5) not in obvious pain (6) no general discoloration H A N D S

(1) Moisture & Temperature Hypercapnea (2) Color (normal = pinkish)

(a) cyanosis (blue) (a) live failure causes high oestrogen

(b) jaundice (b) HA, hepatocellular, obstructive (pre, hepatic and post jaundice)

(c) pallor (c) GI bleeding, parasite, PA in gastric (d) palmar erythema

(d) Liver failure causes high oestrogen and vasodilatation

(e) nicotine staining

(3) Clubbing

= increase in angle between proximal nail and nail Seen in:

 HCC

 IBD

 Liver cirrhosis  Celiac disease

(4) Capillary refill (Normal < 2s) Press for at least 10s.

(5) Leuconychia

=opacity of the nails, leaving a rim of pink nail bed on the top of the nail

Seen in; low albumin level due to :  Liver failure

 Malabsorption  Kidney failure (6) Koilonychia =spoon shaped nails

Due to IDA, may be secondary to malabsoption. (7) Small Muscle wasting in hand Malabsorption

(8) Dupuytren’s contracture

= thickening & shortening of palmar fascia Tendon Xanthomata

1st _{stage = tenderness due to inflammation}

2nd _{stage = thicken & contract due to fibrosis}

Seen in chronic alcoholics

(9) Tremors – flapping tremors

Hypercapnia or hyperuricaemia due to heart failure, respiratory failure, liver failure kidney failure or uraemia A R M S (1) Spider naevi

= central arteriole which radiate numerous small vessels which look like spider legs.

(1) If-more than 5, then it is due to liver cirrhosis {increase in oestrogen}

(2) Scratch mark (2) Hyperuremia due to liver failure (3) Bruising / petechiae /

ecchymosis / purpura (3) Liver failure or Malabsorbtion

(4)Axillary hair (4)Liver failure

E Y E S (1) Jaundice _{(2) Pallor} M O U T H (1) Oral hygiene

(2) Fetor hepaticus (sweet smell breath from methionine)

(2) Hepatocellular disease

(4) Jaundice

(5) Angular stomatitis (5) Iron-deficiency anemia

(6) Glossitis (6) B12-deficiency

(7) Leukoplakia

(7) Leukoplakia

= white colored thickening of the mucosa of the tongue

Caused by:

 Sore teeth (poor oral hygiene)  Smoking  Sepsis  Syphilis C h es t (1) Spider naevi

= central arteriole from which radiate numerous small vessels which look like spider’s leg.

When noticed, press the point and the point will disappear and upon releasing the point appears back.

Seen in alcoholic live cirrhosis

(2) Gynecomastia = enlargement of breast in male_{Seen in chronic liver failure}

A B D O M E N GENERALS

(1) Patient must be supine & flat (2) Hand must be at the side (3) Ask him to breath in / out (4) ASK patient whether he has any pain before touching him (5) WARM hands before touching patient

(6) LOOK at patient’s face while palpating

REMEMBER to ASK for pain, WARM hands and look at the patient’s face while you are palpating his abdomen.

COMMON mistake done by students.

Always try to have the habit of asking, then touch then see patient.

INSPECTION

Vertical lines

=

mid clavicular to mid inguinal point

Horizontal lines =

(1) subcoastal lines - below the 10th _rib

(2) trans-tubercle line - just below L5

**see in extra on how to determine trans-tubercle (1) Size & shape (1) Size and shape

(a) Flat or (a) Normal

(b) Distended or (b) 6Fs (feaces, fat, fluid, fatal growth, flatus, fetus)

(2) Umbilicus

(a) Inverted/sunken

(2) Umbilicus (a) Normal

(b) Flat (b)

(c) Everted (c) ascites, pregnancy

(c) Movement with respiration (3) Reduced movement due to pain if there is _peritonitis

(4) Scar You may asked on different type of scars

(5) Striae (5) Rapid loss or gain of weight, pregnancy, Cushing's syndrome (purple color)

(6) Dilated veins

- if around umbilicus it is known as caput medusa

(6) Liver failure

(7) Obvious peristalsis (7) Intestinal obstruction.

(8) Visible pulsation (8) Aortic aneurysm

(9) Obvious masses PALPATION

Before palpating you have to do a few things.

(1) Explain

(2) Ask for any pain (3) WARM hands

(4) For LIGHT palpation DON'T take your hands up.

DEEP - can lift up your hand. (5) LOOK at patient while you are palpating.

(6) NAME the region while light palpation & go in order (7) Flex joint at hand cup (8) Forearm are at horizontal

Today I am going to touch (or palpate your

abdomen) I would like to start from a place furthest away from any pain you have. Do you have any pain anywhere around your abdomen / tummy? Say for an example patient has no pain

say

"Alright. If you have any pain, please inform me." Then, start wherever you like but be in order.

(1) LIGHT PALPATION Things to say (1) No pain/tenderness (2) No guarding (3) No masses (1) LIGHT PALPATION Things to remember (1) Look at patient (2) Name the regions

(3) DON'T lift up your hand (2) DEEP PALPATION Things to say (I) No pain/tenderness (2) No guarding (3) No masses (2) DEEP PALPATION Things to remember (1) Look at patient

(2) Move in during inspiration (3) CAN lift up your hands

(3) LIVER Things to say

(1) Liver is not palpable

(2) They might ask what you will comment on if the liver edge

was palpable (site, size, shape, consistency, surface, border)

(3) LIVER

Things to remember

(1) Fingers point towards left axilla, parallel to costal margin, lateral to rectus abdominis. (2) START from RIF and slowly

move upwards.

(4) SPLEEN

Things to say; Spleen not palpable

(4) SPLEEN

Things to remember (1) Start from RIF (2) Go towards the LHC (3) Must cross the umbilicus (4) Once reach the costal margin,

move along the costal margin (5) Then lift up the spleen

A B D O M E N PERCUSSION (1) General percussion Say: resonant (1) general percussion

hyperresonant = gas distension

(2) Liver span

Percuss at mid clavicular line Above - 2nd _{ICS; below - RIF}

Normal span = 8 - 12 cm

(3) Spleen

Percuss from RIF

Then percuss the Traub's space

Lines for Traube's space

(a) mid axillary line ( not too sure) (b) xiphisternal

(c) costal margin (4) Shifting dullness

1st _{percuss starting from the}

umbilicus and move laterally. Then say it's resonant and you can't get the point of dullness. The lecturer will ask you to assume 1 point as the point of dullness. Then ask patient to lie towards the opposite direction and say you will wait for 15s. Then start percussing back. If resonant then shifting dullness is present.

(4) shifting dullness Mild to moderate ascites

Amount of fluid must be in the peritoneum for shifting dullness = 500ml

5) Fluid thrill

Ask patient to put hand at the centre reason: to prevent the shock wave

Transmitting through fat and skin

(5) fluid thrill Massive ascites

Minimum amount of fluid = 1000ml (a) increased = gastroenteritis, mechanical

obstruction, blood in gut decreased = paralytic ileus as in generalized peritonitis

(b) stenotic lesions in the blood vessel

(c) liver = inflammation + cancer spleen = infarcts AUSCULTATION

(1) Bowel sounds Once every 10 - 15 s

(2) Aortic bruit, Renal Bruit, Iliac bruit (Know the anatomical position)

GENERAL Jaundice Yellow discoloration of the sclera and skin CAUSE: Hyperbilirubinaemia

Weight and wasting

Failure of GIT to absorb food normally. May lead to weight loss and cachexia

CAUSE:

 GI Malignancy  Alcoholic Cirrhosis

 Folds of loose skin (hanging from abdomen and limbs)-suggest recent wt loss  Obesity can cause fatty infiltration of the liver(non alcoholic

steatohepatitis)-abnormal LFTs

SKIN Pigmentation

CAUSES:

 Generalized: chronic liver disease, especially in haemochromatosis

 Malabsorption - Addisonian-type pigmentation ('sun kissed' pigmentation) of the nipples, palmar creases, pressure areas and mouth



Peutz- Jeghers Syndrome

Freckle-like spots(discrete brown black lesions) around mouth and buccal mucosa And fingers and toes

CAUSE:

 Assoc with hamartomas of the small bowel(50%) and colon(30%) which can present with bleeding and intussusceptions

 Autosomal dominant, Increased risk of GI adenocarcinoma

Acanthosis Nigricans

Brown to black velvety elevations of the epidermis due to confluent papillomas

Site: axilla and nape of the neck

 Assoc rarely with GI carcinoma (especially stomach) and lymphoma, acromegaly, diabetes mellitus, endocrinopathies

Hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber svnd)

Multiple small telangiectasia

Site: lips and tongue, may be anywhere on the skin, when present in GIT -can cause

chronic blood loss or even occasionally torrential bleeding

Cause:

 Assoc A-V malformation in liver may be present  AD condition uncommon

Porphyria cutanea tarda

Fragile vesicles on exposed areas of the skin and heal with scarring Dark urine.

CAUSE :

 Chronic disorder of porphyrin metabolism  Assoc with alcoholism, liver disease, Hepatitis C

Systemic sclerosis

Tense tethering of skin

Often assoc with GER and GI motility disorders

NAILS

Leuconychia CAUSE:

 Chronic liver disease or other disease - hypoalbuminaemia

 Nail beds opacity, often leaving only a rim of pink nail bed at the top of nail  Thumb and index finger bilaterally most often involved

 Compression of capillary flow by EC fluid

Muehrcke's lines

Transverse white lines

CAUSE: Hvpoalbuminaemic states including cirrhosis

Clubbing

CAUSES: Cirrhosis(1/3rd _{pts)- may be related to A V shunting in the lungs resulting in}

arterial oxygen desaturation

Severe long standing chronic liver disease Inflammatory bowel disease

Celiac disease

PALMS Palmar

eyrthema 'liver palms'

Reddening affecting thenar and hypothenar eminences often also-soles of the feet

CAUSES:

 Chronic liver disease

 Also seen: pregnancy, thyrotoxicosis, RA, polycythaemia etc  Maybe a normal finding especially in women

Anaemia Pallor at palmar creases CAUSES: GI blood loss, malabsorption of folate, vit B12,haemolysis(ex:

hypersplenism), chronic disease

Depuytren's Contracture

Visible and palpable thickening and contraction of the palmar fascia causing permanent flexion, most often of the ring finger

Often bilateral and occasionally affects the feet

Assoc with alcoholism (not liver disease), also found in some manual workers(may be familial)

Palmar fascia- abnormally large amounts of xanthine - maybe related to pathogenesis

Hepatic Flap (Asterixis)

Stretch out arms in front, separate fingers, extend wrists, for 15s

Jerky irregular flexion-extension movement at the wrist and metacarpophalangeal joints often accompanied by lat movements of the fingers, rhythmical movements- not synchronous on each side

HEPATIC ENCEPHALOPATHY

Interference with the inflow of joint position sense information to the reticular formation of the brainstem. Rhythmical lapses of postural muscle tone

Occasionally: arms, neck, tongue, jaws and eyelids can also be involved

CAUSES

 Liver failure

 May also occur in cardiac, respiratory and renal failure  Hypoglycaemia

 Hypokalaemia, hypomagnesaemia  Barbiturate intoxication

Bruising

Ecchymoses (large bruising)- clotting abnormalities

CAUSES:

 Hepatocellular damage- interferes with protein synthesis and production of all the clotting factors except F8.

 Obstructive Jaundice- shortage of bile acids in the intestine- may reduce absorption of vitamin K- essential for reduction of clotting factors 279,10

Petechiae

Pinhead-sized bruises

CAUSES:

 Chronic excessive alcohol consumption => BM depression => TCP

 Splenomegaly 2ndary _{to portal HT => hypersplenism =>excessive destruction}

of pits in spleen

 Acute hepatic necrosis => DIC can occur

Muscle Wasting

Late manifestation of malnutrition in alcoholic pts. Alcohol can also cause a proximal myopathy

Scratch marks

Due to severe itch (pruritus)

CAUSES:

 Obstructive or cholestatic jaundice

 Commonly the presenting feature of primary biliary cirrhosis

 Retention of an unknown substance normally excreted in bile? Bile salt deposition in the skin?

Spider naevi

o Consist of a central arteriole from which radiate numerous small vessels which look like spiders' legs

o Range in size from just visible to half a centimeter in diameter

o Their usual distribution is in the area drained by the SVC, so they are found on the arms, neck and chest wall

o Can occasionally bleed profusely

o Pressure applied with a pointed object to the central arteriole causes blanching of the whole lesion.

o Rapid refilling occurs on release of the pressure. o >2 anywhere in the body»»likely to be abnormal CAUSE:

 Cirrhosis (usually due to alcohol), transiently occurs with viral hepatitis, 2nd to 5th months of pregnancy; disappears within 8 weeks of delivery.

 Traditionally attributed to oestrogen excess

Normal hepatic function =>> inactivation of oestrogens(impaired in chronic liver disease)

Oestrogens =>> dilatation effect on the spiral arterioles of the endometrium

Campbell de Morgan spots

Flat or slightly elevated red circular lesions which occur on the abdomen or the front of the chest.

Do not blanch on pressure and are very common

Venous stars

 2-3cm lesions which can occur on the dorsum of the feet, legs, back and the lower chest

 Due to elevated venous pressure and are found overlying the main tributary to a large vein.

 Not obliterated by pressure.

EYES

Jaundice Sclera

Anemia Conjunctiva - pallor

Kayser-

Fleischer rings

Brownish green rings occurring at the periphery of the cornea, affecting the upper pole more than the lower

Slit-lamp examination-often necessary to show them CAUSE:

 Due to deposits of excess copper in Descemet's membrane of the cornea

 Found in : Wilson's disease(a copper storage disease which causes cirrhosis and neurological disturbances)

Usually present by the time neurological signs have appeared Pts with other cholestatic liver diseases can also have these rings

Iritis IBD

Xanthelasma

 Yellowish plaques in the subcutaneous tissues in the periorbital region  Due to deposits of lipids

 May indicate protracted elevation of the serum cholestrol

 Pts with cholestasis: an abnormal lipoprotein (LP X) found in plasma and is assoc with elevation of the serum cholesterol.

 Common in pts with primary biliary cirrhosis

Periorbital purpura

Following proctosigmoidoscopy ('black eye syndrome') - characteristic sign of Amyloidosis (perhaps related to factor X deficiency)

Very rare

Fetor (bad breath)

Causes:

 Faulty oral hygiene

 Ketosis (diabetic ketoacidosis – excretion of ketones in exhaled air)  Uremia (fish breath, an ammonical odor)

 Alcohol, paraldehyde

 Putrid (anaerobic chest infections with large amount of sputum)  Cigarettes

Fetor hepaticus

Sweet smell

CAUSE: Severe hepatocellular disease and may be due to methylmercaptans

These sub-exhaled in breath and may be derived from methionine when this amino acid is not demethylated by a diseased liver. Severe FH- fills the pts room-bad sign and indicates a precomatose condition in many cases. Ask pt -exhale through the mouth

TONGUE Lingua

nigra(black tongue)

 Elongation of papillae over the posterior part of the tongue which appears dark brown

 because of the accumulation of keratin, also due to bismuth compounds  No known cause