This document provides details on the 2nd year curriculum for internal medicine at a university in Skopje, Macedonia. It includes 4 lessons on topics like general examination, vital signs, head and neck examination, and examination of extremities. For each lesson, there are notes on the key assessment points and clinical findings. The document also provides instructions on techniques for measuring pulse, blood pressure, and temperature as part of the physical examination.

1. ‫ﺳ‬‫ﻜ‬‫ﻨ‬‫ﺪ‬‫ﺭ‬‫ﻳ‬‫ﺔ‬ ‫ﻻ‬‫ﺍ‬ ‫ﺟ‬‫ﺎ‬‫ﻣ‬‫ﻌ‬‫ﺔ‬
‫ﺍ‬‫ﻟ‬‫ﻄ‬‫ﺐ‬ ‫ﻛ‬‫ﻠ‬‫ﻴ‬‫ﺔ‬
‫ﺍ‬‫ﻟ‬‫ﺒ‬‫ﺎ‬‫ﻃ‬‫ﻨ‬‫ﺔ‬ ‫ﻣ‬‫ﺮ‬‫ﺍ‬‫ﺽ‬ ‫ﻻ‬‫ﺍ‬ ‫ﻗ‬‫ﺴ‬‫ﻢ‬
2ndyearCurriculumofInternalMedicine
year
1
st
Lesson
Generallook
Pallor,JaundiceandCyanosis
2
nd
Lesson
VitalSigns
3rd
Lesson
Head&neckexamination
Faceandneckveins
4
th
Lesson
Examinationof
Extremities
Clubbing&LLedema
NB:Theartofhistorytakingwillbeincludedineverylesson.
‫ﺍ‬‫ﻟ‬‫ﺒ‬‫ﺎ‬‫ﻃ‬‫ﻨ‬‫ﺔ‬ ‫ﻣ‬‫ﺮ‬‫ﺍ‬‫ﺽ‬ ‫ﻻ‬‫ﺍ‬ ‫ﻗ‬‫ﺴ‬‫ﻢ‬ ‫ﺭ‬‫ﺋ‬‫ﻴ‬‫ﺲ‬ ‫ﺍ‬‫ﻟ‬‫ﺒ‬‫ﺎ‬‫ﻃ‬‫ﻨ‬‫ﺔ‬ ‫ﻣ‬‫ﺮ‬‫ﺍ‬‫ﺽ‬ ‫ﻻ‬‫ﺍ‬ ‫ﻟ‬‫ﻘ‬‫ﺴ‬‫ﻢ‬ ‫ﺍ‬‫ﻟ‬‫ﺘ‬‫ﻌ‬‫ﻠ‬‫ﻴ‬‫ﻤ‬‫ﻲ‬ ‫ﺍ‬‫ﻟ‬‫ﻤ‬‫ﻨ‬‫ﺴ‬‫ﻖ‬ ‫ﺍ‬‫ﻟ‬‫ﺜ‬‫ﺎ‬‫ﻧ‬‫ﻴ‬‫ﺔ‬ ‫ﺍ‬‫ﻟ‬‫ﺴ‬‫ﻨ‬‫ﺔ‬ ‫ﻣ‬‫ﻨ‬‫ﺴ‬‫ﻖ‬
‫ﺍ‬‫ﻟ‬‫ﺴ‬‫ﻜ‬‫ﺮ‬ ‫ﻭ‬‫ﺣ‬‫ﺪ‬‫ﺓ‬ ‫ﻭ‬‫ﺭ‬‫ﺋ‬‫ﻴ‬‫ﺲ‬ ‫ﻳ‬‫ﻮ‬‫ﺳ‬‫ﻒ‬ ‫ﺍ‬‫ﻳ‬‫ﻤ‬‫ﺎ‬‫ﻥ‬ /‫ﺃ‬‫ﺩ‬ ‫ﺏ‬‫ﻼ‬‫ﻏ‬ ‫ﻋ‬‫ﻤ‬‫ﺮ‬ /‫ﺩ‬ ‫ﺃ‬‫ﻡ‬
‫ﺍ‬‫ﻟ‬‫ﻌ‬‫ﺎ‬‫ﻃ‬‫ﻲ‬ ‫ﻋ‬‫ﺒ‬‫ﺪ‬ ‫ﻃ‬‫ﻠ‬‫ﻌ‬‫ﺖ‬ /‫ﺃ‬‫ﺩ‬ ‫ﺍ‬‫ﻟ‬‫ﺨ‬‫ﻮ‬‫ﻟ‬‫ﻲ‬ ‫ﻧ‬‫ﻬ‬‫ﻰ‬ /‫ﺩ‬

2. I
1.Generallook
I.Pallor:
 Lossoftheusual(natural)coloroftheskin.
 Pallorisdetectedintheskinoftheface,outeraspectofthelipandpalmofthehands.
 Itisalsodetectedinthemucousmembraneofconjunctivaandinneraspectofthelip.
II.Cyanosis:
 Itisabluishdiscolorationofskin&mucousmembranesduetothepresenceofexcessivereduced
hemoglobininthearterialcirculation(morethan5gm/dl).
 ItcouldbeCentralcyanosis,orPeripheralcyanosis.
 Centralcyanosis:bluecolorisdetectedintheundersurfaceoftongueandinnerlip.
 Peripheralcyanosis:bluecolorinnails,outerlip,earlobuleandtipofthenose.
Mechanismofcentralcyanosis:duetodefectinthesaturationofarterialbloodbythelung.
 Theextremitiesarewarmduetoperipheralvasodilatation(hypoxemiaiscompensatedby
polycythemia).
 ThearterialO2saturationisdecreased.
 Clubbingoffingersmaybepresent
Mechanism ofperipheralcyanosis:duetostagnationofthebloodintheperipheralcirculationgiving
moretimeforextractionofoxygenandadditionofcarbondioxide.
 Theextremitiesarecoldduetoperipheralvasoconstriction,so,warmingtheextremitiesleadsto
disappearanceofthecyanosis.
 ThearterialO2saturationisnormal.
 Noclubbingoffingers.
III.Jaundice:
 Yellowishcolorationoftheskinandmucousmembraneduetoincreaseintheserum
bilirubin
(2.5 to3mg/dl).
 Subclinicaljaundice:theserumbilirubinuptomg/dl.
 Normalserumbilirubin:0.2to1mg/dl.
 Itisdetectedintheskinandmucousmembraneofthesclera.
 Types:
1.Haemolytic(prehepatic):
 Thereisexcessproductionofunconjugatedbilirubin→Unconjugatedhyperbilirubinemia.
 Thereisexcessproductionofstercobilinogenandurobilinogen.
2.Hepato-cellular(hepatic):
 Failureofthelivertoconjugateallunconjugatedbilirubin→Unconjugatedhyperbilirubinemia.
 Failureofthelivertoexcreteallconjugatedbilirubin→Conjugatedhyperbilirubinemia.
3.Obstructive(posthepatic):
 Extrahepaticbiliaryobstruction:Stoneinthecommonbileductandcarcinomaofheadofthe
pancreas.
 Intrahepaticbiliaryobstruction:primarybiliarycirrhosisanddrugs(sulfonylurea).
 Thecholebilirubincannotbeexcretedintheintestinewhichretainedintheblood→Conjugated

3. II
hyperbilirubinemia.
 Excessexcretionofcholebilirubininurine.
 Excessexcretionofbilesaltsinurine(→frothyurine)anditsretentionintheblood(→iching,
bradycardia).
 Nosterchobilinogeninthestoolandnourobilinogenintheurine.
2.Vitalsigns
I.Pulse
Technique:
1.Greetingthepatient,standonhisrightside,introduceyourselfandexplaintothepatientwhatyou
aregoingtodo.
2.Assistthepatienttopronateandslightlyfixtheforearmonhischest
3.Usetherighthandtopalpatethepatient'sleftradialpulseandviceversa.
4.Placethetipsofthemiddlethreefingersontheradialartery((theradialsideofthepalmeraspect
ofthewrist,abouttwocentimetersproximaltothethenareminence)).
5.Pressgentlytillyoufeelthepulse.
6.Countthepulseincompleteoneminuteevenitiscompletelyregular.
7.Commentonthefollowingpoints:
1)Rate
2)Rhythm
3)Force
4)Volume
5)Specialcharacter
6)Equalityonbothsides
7)Vesselwall
8)Peripheralpulsations.
8.Thanksthepatient.
►Rate:
Normally: 60-100beat/min.
Abnormally:bradycardia(<60)ortachycardia(>100).
►Rhythm:--normallythedistancebetweeneachtwoconsecutivebeatsisequal.
--Thepulsemayberegularorirregular.
--Theirregularityiseither:regularirregularityorirregularirregularity;
i.Regularirregularity:youcancount4-6consecutivebeatsregularinoneminute.
ii.Regularirregularity:(completelyirregularpulse)Themostcommoncause
isatrialfibrillation(AF).
►Force:
 Itistheamountofpressureinducedbytheproximalfingertillthemiddlefingerfeelsnopulsations.
 Itsignifiesthesystolicbloodpressure.
 Itismeasuredbyapplyingthemiddlethreefingersontheradialpulse.Thedistaloneservestocut
offanypulsationscomingupthroughthecollateralarterialpalmerarchofthehand,themiddleis
theindicatorthatwillfeelthepulsation,andtheproximalfingerisusedtoapplypressureoverthe

4. III
wallofthearterytilltheindicatorfingerstopfeelingpulsation.Theamountofthispressureis
directlyproportionaltosystolicbloodpressure.
 Theforceofthepulseeithernormal,increaseordecrease.
►Volume:
 Itistheamountofexpansionofthearterywitheachpulsation.
 Itsignifiesthepulsepressure(differencebetweensystolicanddiastolicbloodpressure).
 Averagepulsepressureis(40-60)mmHg.
►Specialcharacter:(maybebetterassessedincarotid,brachialorfemoralarteriesbecausethecloserto
theheart)
 Waterhammerpulse(collapsingpulse):suddenrise,suddencollapsewithwidepulsepressure.
Acollapsingpulseoccursinaorticregurgitationwhenthepeakofthepulsewaveoccurearly(rapidup
stroke)andisfollowedbyarapiddescent(rapiddownstroke).Thisrapidfallinpulsepressure
impartsthe'collapsing'sensation.Itisexaggeratedbyraisingthepatient'sarmwellabovethelevelof
theheart.Thepulsepressureismorethan60mmHg.
►Arterialwall:normallythevesselwallisnotfelt.Itisfeltinatherosclerosis.
►Equalityonbothsides:
 Therateandrhythmshouldbesimilaronbothsides.
 Inequalityreferstotheforceandvolumeofthepulsewhichcausedby:

5. IV
Bloodpressure
Rules:
 Thepatientisinsittingpositionafter5minutesrest.
 3partsshouldbesupported:back,feetandthearm.
 Thecuffshouldbeatthelevelofmidsterumcuff((itshouldbeappliedcloselytotheupperarm,
withthelowerbordernotlessthan2cmfromthecubitalfossa)).
 Itshouldnotbewrappedverytightorveryloose.
 The2rubbertubesshouldbeadjustedduringwrappingthecufftobeinthemiddleofthecubital
fossa.
 Themanometerisplacedsoastobeatthesamelevelastheobserver'seyeandthecardiaclevel.
 Thediaphragmofthestethoscopeispositionedatthelowermarginofthecuffoverthebrachial

6. V
artery((medialwallofthecubitalfossa)).
 Stratpalpatorytheauscultatorymethod.
Technique:
i.Palpatorymethod:
1)Thecuffisinflatedgraduallyuntiltheobliterationpressure:itisthepressureatwhichtheradial
pulseisnolongerpalpable.
2)Deflatethecuffthendotheauscultatorymethod.
ii.Auscultatorymethod:
1)inflatethecufffor30mmHgabovetheobliterationpressure.
2)Thecuffpressureisslowlyreducedtohearthe(Korotkoffsounds)(5phases):
 ThefirstsoundtohearisthesystolicBP.(Phase1)
 Thenthesoundbecomesmurmurish.(Phase2)
 Thenthesoundincreasesinintensity.(Phase3)
 Thenthesounddecreasesinintensity.(Phase4)
 ThenthesounddisappearswhichisthediastolicBP.(Phase5)
Thevalueofthepalpatorymethodistoavoidunderestimationofseveresystolichypertensionduetothe
presenceofidiopathicphenomenoncalledauscultatorygap.
.
ClassificationofbloodpressurelevelsoftheBritishHypertensionSociety
Systolicbloodpressure(mmHg) Diastolicbloodpressure(mmHg)
Average 120 80
Hypertension
GradeI(mild) 140-149 90-99
Grade2(moderate) 160-179 100-109
Grade3(severe) ≥180 ≥110
 Inthelowerlimb:theSBPishigherby10–30mmHg.
 Adifferenceof10mmHgoccursin25%ofhealthyindividualsinbetweenbotharms.
III.Temperature
Thenormalrangeofbodytemperature(measuredorally)ofthehealthypersonis36.7ºC–37.3ºC.
Thethreelocationsnormallyusedindeterminingthebodytemperatureare:

7. VI
 Themouth(oraltemperature)
 Therectum(rectaltemperature)
 Thearmpit(axillarytemperature).
Theaxillarytemperatureis0.5ºClowerthantheoraltemperature.Whiletherectaltemperatureis0.5ºC
higherthantheoraltemperature.
AHoldingthethermometer.
BRotatingthethermometer.
DtemperatureonaCelsius(Centigradescale)thermomete
Measurementofbodytemperature:
1.Greetingthepatient,standonhisrightside,introduceyourselfandexplaintothepatientwhatyou
aregoingtodo.
2.Preparethethermometertray;mercurythermometer,alcohol,andcottonballs.
3.Washthehands.
4.Holdthethermometerattheendofthestem,withthefingertipsoftherighthandateyelevel.
5.Rotateslowlythethermometerbackandforthuntilthemercuryintheshaftisclearlyvisible.
6.Wipethethermometerbycottonballsandalcohol.
7.Shakethethermometerdownto35°Cusingquick,sharp,downwardwristmotions.
8.Incaseofaxillarymethod;
 Askthepatienttolieinasupineorsemi-sittingposition.
 Placethebulbofthethermometerinthepatient’sclean,dryaxilla
 Holdthearmofthepatientfirmlytothesidewiththeelbowflexedandthehandincontactwiththe
chest.
 Waitatleast3minutesbeforeremovingthethermometer.
 Removethethermometerfromtheaxillaanddryitbywipingbycottonballsfromthestemtothe
bulb.

8. VII
 Readthethermometerbyholdingitateye-levelandrotatingthestemuntilthemercuryisclearly
seen.
 Recordtheresultsbyadding0.5ºCtothemeasuredtemperature.
9.Incaseoforalmethod;
 Askthepatienttoopenhismouthandraisehistongue.
 Placethebulbofthethermometeronaheatpocketlocatedonthefloorofthemouthatthebase
ofthetongue
 Tellthepatienttorelaxhistongue(thuscoveringthebulbofthethermometer)andtoclosehislips
firmlyoverthethermometer
 Waitatleast3minutesbeforeremovingthethermometerfromthepatient’smouth.
 Removeanysecretionsfromthethermometerbywipingbycottonballsfromthestemtothebulb.
 Readthethermometerbyholdingitateyelevelandrotatingthestemuntilthemercuryisseen
clearly.
10.Thanksthepatient.
Hypothermia:(<35°C).
Hyperpyrexiaisacoretemperature>41°Candmaybefatal.
IV.Respiratoryrate
 Thenormalrateofrespirationinarelaxedadultisabout14-16breathsperminuteinmale.
And16-18breathsperminuteinfemale.
 Tachypneaisanincreasedrespiratoryrateobservedbythedoctor.
 Apneameanscessationofrespiration.
 CounttheRRincompleteoneminute.
3.Head&neckexamination
Theface
Malarflushoftheface
 erythematousrashonthebutterflyareaoftheface:Mitralstenosis
 Malarpigmentation:pellagra

9. VIII
Eyeexamination
a)Lossofhairintheouter1/3oftheeyebrows:Myxedema
b)Puffinessoflowereyelids:
c)Pallor: “intheconjunctiva”
d)Jaundice:inthesclera
e)Exophthalmos:inThyrotoxicos
f)Xanthelasma:indicatehyperlipidemia.
Odorofthemouth
a)Fruity(acetone)odorofthemouthisdueto:ketoacidosis
b)Odorofammonia:inhepaticfailureanduremia
Tongueexamination
a)Cyanosis
b)Coatedtongue:
c)Drytongue:
d)Redglazedtongue:
Toxicface
 Infectiveendocarditis.
 Septicemia.
 Maignancy.
NeckVeins
 JugularVenousPulse(JVP)reflectschangesintherightatriumthroughoutthecardiaccycle.
 Identification:thereare2jugularveinsoneachsideoftheneck:
 Externaljugularvein:Easytosee,butgivesfalseimpressionofraisedpressure.
 Internaljugularvein:Moredifficulttosee,butisaccurateformeasurementofpressure&
pulsations.Itsexaminationdependsondetectionofitspulsations.Itrunsdeeplyfromthesterno-
clavicularjointupwards&laterallytotheangleofthejaw(theverticallineoftheneck).
▪BothcanbeidentifiedbyaskingthepatienttoperformaValsalvamaneuver.
Comment:Neckveinsshouldbeexaminedfor:
1.Thedegreeofvenouscongestion
-Usually,theheadofthebedneedsslightelevation(45ºfromthehorizontal).However,when
thepatient’svenouspressureisincreased,theheadofthebedmayneedmoreelevationupto
60ºoreven90º.Inallthesepositions,thesternalangleremainsabout5cmabovetheright
atrium.
Measuring:
Thepatientispositionedatabout45°tothehorizontal(between30°and60°),wherever
thetopofthevenouspulsationcanbeseeninagoodlight.Thejugularvenouspressureis
measuredastheverticaldistancebetweenthemanubriosternalangleandthetopofthevenous
column.Thenormaljugularvenouspressureisusuallylessthan3cm,whichisequivalenttoa
rightatrialpressureof8cmwhenmeasuredwithreferencetoapointmidwaybetweenthe
anteriorandposteriorsurfacesofthechest.Thevenouspulsationsarenotusuallypalpable
(exceptfortheforcefulvenousdistensionassociatedwithtricuspidregurgitation).Venous
pressuregreaterthan3cmabovethesternalangleisconsideredelevatedwiththepatientinany
position).

10. IX
2.Pulsations:(pulsatingornot??)
 Normally,theJVpulsationsarewavy&consistof3positivewaves:
 Awave:rightatrialcontractionwhilethetricuspidvalveisopened.Itisapresystolic
wave.
 Cwave:Upwardbulgeoftricuspidvalveintorightatriumduetoitssuddenclosure.
 Vwave:rightatrialfillingduringventricularsystolewhilethetricuspidvalveisclosed.itisa
systolicwave.
and2negativewavesxandy.
Clinicalsignificanceofneckveins:
1)Abnormalpressure: Congestedneckveins
 Congestedpulsating:
 Congestednon-pulsating:
2)AbnormalPulsations: Abnormalwaves
Differencebetweenvenousandarterialpulsations
Venouspulsations Arterialpulsations
wavy single
Betterseenthanfelt Betterfeltthanseen
Effectofinspiration Emptywithinspiration Noeffect
Effectofcompressionofthe
rootofneck
Morecongested Noeffect
Effectofchangeofposture Significant Noeffect
4.ExaminationsofExtremities
I.Edemaofthelowerlimbs
 Examination:

11. X
 Pressfirmlywithyourthumbfor15-30secondsbehindeachmedialmalleolus,overthedorsumof
eachfoot&overtheshins.
 Lookforpitting:adepressionintheskincausedbypressure.
 Checkforsacraledemainbedriddenpatients.
 PalpatethecalfmusclesforsignsofDVT: calfmusclesare firm,tense&tender.
 Lookforsignsofinflammation:redness,hotnessordiscoloration.
 TypesofLLedema:
 GeneralizedEdema(bilateraledema):cardiac,renal,hepaticandnutritional.
 LocalizedEdema(unilateraledema):e.g.,allergic
Characteristics:
a)Cardiacedema:
i. Occursinthedependentpartsofthebody(gravitational):
a. Ankleedema:inambulantpatients.
b. Sacraledema:inbedriddenpatients.
ii. Bilateralandequalinbothsides.
iii. Alwayspitting,firmbecausetissuefluidisrichinprotein.
iv. Edemaoflowerlimbsalwaysprecedesappearanceofascites,exceptintwoconditions
inwhichascitesoccursfirst“Ascitesprecox”:Pericardialeffusion&constrictivepericarditis
andtricuspidvalvedisease.Themostimportantcauseofascitesprecoxisconstrictive
pericarditis.
b) Renaledema:Thisoccursinnephritisornephriticsyndromes.Edemaoccursfirstintheeye
lidsandisassociatedwithfeaturesofrenaldisease.
c) Hepaticedema:Edemaoflowerlimbsoccursafterascitesandisassociatedwithfeatures
ofliverdisease.
d) Nutritionaledema:Edemaoccursfirstinthelowerlimbsandisassociatedwithfeaturesof
nutritionaldeficiencies.
e) Allergicedema:Edemaoccursacutelyespeciallyinthelips,eyelids&larynx,butmaybe
generalized.Ifitaffectsthetongueandlarynx;itmaybelifethreatening.Thereisusually
positivefamilyhistoryofedemaorotherallergies,andthepatienthimselfmayhaveother
formsofallergy.Rapidresponseofedematoanti-allergicmeasuresischaracteristic.

12. XI
Pittingornon-pittingedema:
 Non-pittingedemaiseitherduetolymphedema,allergic,myxedema,orinflammatory.
 Pittingedema(pitsonpressure)isduetoothercausesofedema.
Pathogenesisofedema:
 Increasedcapillaryhydrostaticpressure.
 Increasedvenouspressure.
 Saltandwaterretention.
 Hypoalbuminemia.
 Increasedcapillarypermeability
 Resistancetotheactionoftheatrialnatriureticpeptide(ANP).
 Impairedlymphdrainage.
II.Clubbingofthenails
Itisaconditioncharacterizedbybulbousenlargementofthedistalphalangesofthefingersandtoesdue
totissueproliferationofthenailbedsecondarytochronictoxemiaorhypoxia.
Degrees:
1.First: obliterationoftheangleatthenailbed.
2.Second: Parrotbeakappearancedueto↑curvatureofthenail(antero-posterior,sidetosideor
both).
3.Third: Drumsticksappearance.
4.Fourth:(pulmonaryosteoarthropathy):Drumsticksappearanceandswellingofthewristjoint
togetherwithswellingofthelowerendsofradiusandulna(periostitis).
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