medical students

1. PREPARED BY: MD 151
General physical examination
The four principles of examination
1- Inspection/looking
2 –palpation/feeling
3 - Percussion/tapping
4 –Auscultation/listening
Important points:
1- Wash your hands in front of the patient before the examination
2- Come to the right side of the patient
3- Great the patient and introduce your self
4- Take consent from the patient
5- Ask the patient if there is tenderness anywhere
6- Properly expose the patient
7- After the examination is done, cover the patient and thank him/her
1- General Appearance:
Come to the foot end of the bed and have a general look of the patient.
1- Assess the degree of the patient’s consciousness and illness whether he looks well,
mildly ill, severely ill or deeply comatose.
2- Posture and attitude
❖ Cardiac bed indicating respiratory or cardiac problem
❖ Pt bending forward indicating pancreatitis and pericarditis
❖ Squatting position indicating tetralogy of fallot
3- Gait
❖ Assess the patient as he walks towards you the gait may suggest an important
neurological or masculoskeletal disorders
4- Physique
❖ Height and weight
✓ Marfan syndrome and hypogonadism the arm span is more than double the
sitting height.
✓ Achondroplasia arms and legs are short while trunk is normal, so sitting
height is more than length of legs as measured from pupis to feet.

2. PREPARED BY: MD 151
✓ Pituitary dwarf the total height is less than the normal but limbs and trunk
are proportionate
2-Hand:
A. Palm
➢ Palmar erythema: pregnancy, liver cirrhosis, hemochromatosis and polycythemia.
➢ Pallor: pale in anemia
➢ Muscle wasting: RA and median nerve compression
➢ Debuytrens’s contracture: liver cirrhosis, Dm, epilepsy and alcoholism.
Grades:
1-loss of extension
2- partial flexion
3-complete flexion
B. Dorsum
➢ Skin pigmentation
➢ Janeway nodules: IE
➢ Heberden’s nodule in the joints: osteoarthritis
➢ Deformity: ulnar deviation indicating RA
C. Nails
➢ Kolinychia: Iron deficiency anemia
➢ Splinter hemorrhage: IE, antiphospholipid syndrome, trauma to the nail, nail
psoriasis, rheumatic heart disease and SLE.
➢ Capillary pulsations: Aortic regurge
➢ Leukonychia: hypo-proteinemia
➢ Clubbing:
▪ Grades
1- Loss of schamroth angle
2- Increase curvature
3- Fluctuations
4- Drum stick
▪ According to colour:
1- Pink: toxemic clubbing indicating IE
2- Bule: hypoxemicclubbing associated with peripheral cyanosis
▪ CAUSES
1)Cardiovascular: cyanotic congenital heart disease and IE
2) Respiratory: lung carcinoma, bronchiectasis, lung abscess and empyema

3. PREPARED BY: MD 151
3)Gastrointestinal: cirrhosis ,IBS and Coeliac disease
4)Thyrotoxicosis
D. tip of the fingers
➢ Peripheral cyanosis
Causes of Peripheral cyanosis
1)Decreased arterial oyygen saturation.
-high altitude
-lung disease
-right to left cardiac shunt
2)Polycythaemia
3)Haemoglobin abnormalities;methaemoglobinemia,sulphaemoglobinemia
4)Exposure to cold
5)Reduced cardiac output as in
-left ventricular failure
-shock
6)Arterial or venous obstruction
➢ Osler nodules: seen in IE, Gonococcal infection and SLE.
3. Pulse
1-Rate
• 60-100 normal
• >100 tachycardia
• <60 bradycadia
2-Rhythm: [regular- regular, regular-irregular,and irregular- irregular]
3- volume (pulse pressure)
• High volume as in increased SBP: Aortic incompetence, thyrotoxicosis and
bradycardia
• High volume as in decreased DBP: anemia, hypoxia, pregnancy and sepsis.
• Low volume: HF, hypovolemia, MI, pulmonary hypertension and pericardial
diseases as in effusion and pericarditis
4-character
• Collapsing pulse or water hammer pulse: High volume
• Pulse alternative: dilated cardiomyopathy and left ventricular hypertrophy
• Pulses plateau: Aortic stenosis

4. PREPARED BY: MD 151
5-synchronicity
▪ Causes of radio-radial delay
Outside the wall: cervical rib and pancoast tumor.
In the wall: Aneurysm ( Aortic or subclavian ), Dissection of the Aorta
including the subclavian and aortic arch coacrtation.
In the lumen: Thrombosis and Embolism.
▪ Exanples of radioradial delay or not synchronous: Takayasu arteritis,
Obsrtuction, Aortic dissection and subclavian steal syndrome
7-radio-femoral delay: Coacrtation of the aorta
8-Peripheral pulse: carotid, brachial, femoral, popliteal, posterior tibial and dorsalis
pedis.
▪ Comment: the pulse is 72p/m regular, normal in volume synchronous with no
radiofemoral delay, peripheral pulse is intact and present and there is obvious
character seen in pulse.
4. Blood Pressure
❖ Normal blood pressure ranges
✓ Systolic from 90 to 140mmhg
✓ Diastolic from 60 to 90mmhg
❖ How to measure the blood presuure
1- The Bp cuff bladder should be at least 20% wider than the arm
2- The patient should be relaxed and the arm at the level of the heart
3- Wrap the cuff at least 2cm above the cubital fossa
4- Palpate the brachial pulse medial to the biceps tendon and use this area for
auscultation
5- First assess the systolic Bp by palpation of the radial artery to avoid
auscultatory gap
6- Auscultate for the SBP by rising the pressure of the sphygmomanometer until
the brachial pulse is obliterated then deflate the cuff slowly at a rate of
3mmhg/sec
7- The point at which the sound appears is the SBP
8- Then continue to deflate till the point of diastolic muffling and the point of
diastolic disappearance which is recorded as DBP
NB: the difference of both upper limb ranges between 5 to 10mmhg.
▪ Causes of larger difference ( more than 15mmhg )
Same causes of unequal pulse volume importantly to exclude life threatening
aortic dissection

5. PREPARED BY: MD 151
NB: the normal difference between the upper limb and the lower limp is less than
20mmhg.
▪ Indications to measure the BP from the lower limb
1- To diagnose lower limb ischemia
2- To diagnose coarctation of the aorta
3- To diagnose increased volume as in aortic regurge ( Hill sign )
5. Face
⚫ Specific diagnosis can be made by just looking at a patient’s face.
⚫ Some facial characteristics are so typical of certain diseases that they immediately
suggest the diagnosis….so called diagnostic facies
Acromegaly

6. PREPARED BY: MD 151
Down syndrome Thyrotoxicosis
Cushing’s syndrome

7. PREPARED BY: MD 151
❖ Hair
- Random alopecia: chemotherapy
- Colour change: malnutrition
- Distribution
❖ Eye
-look up: pallor indicating Anemia
-look down: yellowish discoloration of the sclera indicating jaundice
-subconjunctival hemorrhage:
- Bitot spots: vitamin A deficiency
-Kayser-fleischer ring: Wilson’s diseases
-corneal ulcers
-cataract: Dm and hypertension.
❖ Nose
-anomaly
-discharge
-working ala nasi: respiratory distress syndrome
❖ Ear
-anomaly
-discharge
❖ Mouth
-blue dot discoloration in lips: central cyanosis
-angular stomatitis
-cavity: congenital anomaly and hygiene
-tongue: macroglossia, red pink in clour,
leukoplakia, ulcer, fissure and bald(smooth) tongue
6. Neck
1) Neck mass
-Thyroid enlargement: midline moving with Swallowing
-Thyroglossal cyst: midline below adam’s apple,small in size, moves with swallowing
With tongue protrusion
-lipoma
Sepacious cyst
2) Lymph node
-During palpation of lymph nodes the following features should be considered;
⚫ SITE
-Localised or generalized
⚫ Number
⚫ SIZE
-normal lyph nodes are <5cm in diameter

8. PREPARED BY: MD 151
⚫ CONSISTENCY
-hard are suggestive of carcinoma
-soft may be normal
-rubbery may be due to lymphoma
⚫ TENDERNESS
-Acute infection of inflammation
FIXATION
-If fixed to the underlying structures its most likely malignant
OVERLYING SKIN
-if inflammed then its suggestive of infection,teethered suggests carcinoma.
-left supraclavicular lymphnode “ Virshow lymphnode” if palpable “ Tousers sign”
indicating pancreatic or gastric malignancy.
-Epitrochlear if palpable indicating generalized lymphadenopathy
CAUSES OF LYMPHADENOPATHY
⚫ GENERALISED
-lymphoma
-leukemia
-infections

9. PREPARED BY: MD 151
-viral;infectious mononucleosis,CMV,HIV
-bacterial;tuberculosis,syphilis
-protozoal;toxoplasmosis
-connective tissue disease
-infitration;sarcoidosis
-drugs;phenytoin
• Localized
Local or acute infection
Metastasis from carcinoma or other solid tumour
Lymphoma especially hodgkin’s disease
3) JVP
-Examine the patient from the right side while head of the bed is elevated about 45
degree.
-Look for venous pulsations in the internal jugular vein along the anterior border of the
sternocleidomastoid and measure vertical distance from the highest of venous pulsations
to the sternal angle.
-If it’s more than 3cm it is abnormal and indicates right side heart failure.
Characters of JVP
1- wavy form
2 -disappears on pressure
3-positive hepatojugular reflex
Causes increased JVP
-svc obstruction
-restrictive cardiomyopathy
-constrictive pericarditis
-right ventricular failure
Kussmaul sign: increases with inspiration
-restrictive cardiomyopathy
-constrictive pericarditis
Jugular vein distended but not wavy: SVC obstruction associated with chest vein
dilations.