This document outlines the curriculum for the second year of internal medicine studies at Alexandria University Faculty of Medicine. It lists 4 lessons on general examination techniques: 1) appearance of pallor, jaundice, and cyanosis; 2) vital signs including pulse, blood pressure, temperature, and respiratory rate; 3) head and neck examination focusing on the face, eyes, mouth, tongue, and neck veins; and 4) extremity examination of clubbing and leg edema. Key points are provided on assessing each of these exam findings and their clinical significance. The coordinator for the second year internal medicine curriculum signs off on the document.

1. ‫االسكندرية‬ ‫جامعة‬
‫الطب‬ ‫كلية‬
‫الباطنة‬ ‫االمراض‬ ‫قسم‬
d year Curriculum of Internal Medicine year2n
st1
Lesson
General look
Pallor , Jaundice and Cyanosis
nd2
Lesson
Vital Signs
3rd
Lesson
Head & neck examination
Face and neck veins
th4
Lesson
Examination of
Extremities
Clubbing & LL edema
NB: The art of history taking will be includedin every lesson.
‫الثانية‬ ‫السنة‬ ‫منسق‬‫الباطنة‬ ‫االمراض‬ ‫قسم‬ ‫رئيس‬ ‫الباطنة‬ ‫االمراض‬ ‫لقسم‬ ‫التعليمي‬ ‫المنسق‬
‫السكر‬ ‫وحدة‬ ‫ورئيس‬ ‫يوسف‬ ‫ايمان‬ / ‫أد‬ ‫غالب‬ ‫د/عمر‬ ‫أم‬
‫العاطي‬ ‫عبد‬ ‫طلعت‬ /‫أد‬ ‫الخولي‬ ‫نهى‬ / ‫د‬

2. 1
1.General look
I.Pallor:
 Loss of the usual(natural) color of the skin.
 Pallor is detected in theskin of the face, outer aspect of the lip and palm of the hands.
 It is also detected in the mucous membrane ofconjunctiva and inner aspect of the lip.
II. Cyanosis:
 It is a bluish discoloration of skin & mucous membranes due to the presence of excessive reduced
hemoglobin in the arterial circulation (more than 5 gm /dl).
 It could be Central cyanosis, or Peripheral cyanosis.
 Central cyanosis: blue color is detected in the under surface of tongue and inner lip.
 Peripheral cyanosis: blue color in nails, outer lip, ear lobule and tip of the nose.
Mechanism of central cyanosis: due to defect in the saturation of arterial blood by the lung.
 The extremities are warm due to peripheral vasodilatation (hypoxemia is compensated by
polycythemia).
 The arterial O2 saturation is decreased.
 Clubbing of fingers may be present
Mechanism of peripheral cyanosis: due to stagnation of the blood in the peripheral circulation giving more
time for extraction of oxygen and addition of carbon dioxide.
 The extremities are cold due to peripheral vasoconstriction , so, warming the extremities leads to
disappearance of the cyanosis.
 The arterial O2 saturation is normal.
 No clubbing of fingers.
III. Jaundice:
 Yellowish coloration of the skin and mucous membrane due to increase in the serum bilirubin
(2.5 to 3 mg/dl).
 Subclinical jaundice : the serum bilirubin up to mg/dl.
 Normal serum bilirubin : 0.2 to 1 mg/dl.
 It is detected in the skin and mucous membrane of the sclera.
 Types:
1. Haemolytic (pre hepatic):
 There is excess production of unconjugated bilirubin→Unconjugated hyperbilirubinemia.
 There is excess production of stercobilinogen and urobilinogen.
2. Hepato-cellular (hepatic):
 Failure of the liver to conjugate all unconjugated bilirubin→Unconjugated hyperbilirubinemia.
 Failure of the liver to excrete all conjugated bilirubin→Conjugated hyperbilirubinemia.
3. Obstructive (post hepatic) :
 Extrahepatic biliary obstruction: Stone in the common bile duct and carcinoma of head of the pancreas.
 Intrahepatic biliary obstruction: primary biliary cirrhosis and drugs(sulfonylurea).
 The cholebilirubin cannot be excreted in the intestine which retained in the blood→Conjugated
hyperbilirubinemia.
 Excess excretion of cholebilirubin in urine.
 Excess excretion of bile salts in urine(→frothy urine) and its retention in the blood(→iching, bradycardia).
 No sterchobilinogen in the stool and no urobilinogen in the urine.

3. 2
Vital signs2.
I.Pulse
Technique:
1. Greeting the patient, stand on his right side, introduce yourself and explain to the patient what you are going
to do.
2. Assist the patient to pronate and slightly fix the forearm on his chest
3. Use the right hand to palpate the patient's left radial pulse and vice versa.
4. Place the tips of the middle three fingers on the radial artery ((the radial side of the palmer aspect of the
wrist, about two centimeters proximal to the thenar eminence)) .
5. Press gently till you feel the pulse.
6. Count the pulse in complete one minute even it is completely regular.
7. Comment on the following points:
1) Rate
2) Rhythm
3) Force
4) Volume
5) Special character
6) Equality on both sides
7) Vessel wall
8) Peripheral pulsations.
8. Thanks the patient.
► Rate:
 Normally: 60-100 beat / min.
 Abnormally: bradycardia (< 60) or tachycardia ( >100).
► Rhythm: --normally the distance between each two consecutive beats is equal.
--The pulse may be regular or irregular.
--The irregularity is either:regular irregularity or irregular irregularity;
i. Regular irregularity: you can count 4-6 consecutive beats regular in one minute.
ii.Regular irregularity: (completely irregular pulse) The most common cause
is atrial fibrillation(AF).
► Force:
 It is the amount of pressure induced by the proximal finger till the middle finger feels no pulsations.
 It signifiesthe systolic blood pressure.
 It is measured by applying the middle three fingers on the radial pulse. The distal one serves to cut off any
pulsations coming up through the collateral arterial palmer arch of the hand, the middle is the indicator that
will feel the pulsation, and the proximal finger is used to apply pressure over the wall of the artery till the
indicator finger stop feeling pulsation. The amount of this pressure is directly proportional to systolic blood
pressure.
 The force of the pulse either normal ,increase or decrease .
► Volume:
 It is the amount of expansion of the artery with each pulsation.
 It signifies the pulse pressure (difference between systolic and diastolic blood pressure).
 Average pulse pressure is (40-60) mmHg.

4. 3
► Special character: (may be better assessed in carotid, brachial or femoral arteries because the closer to the heart)
 Water hammer pulse (collapsing pulse): sudden rise,sudden collapse with wide pulse pressure.
A collapsing pulse occurs in aortic regurgitation when the peak of the pulse wave occur early (rapid up stroke)
and is followed by a rapid descent (rapid down stroke). This rapid fall in pulse pressure imparts the 'collapsing'
sensation. It is exaggerated by raising the patient's arm well above the level of the heart.The pulse pressure is
more than 60 mmHg.
► Arterial wall: normally the vessel wall is not felt.It is felt inatherosclerosis.
► Equality on both sides:
 The rate and rhythm should be similar on both sides.
 Inequality refers to the force and volume of the pulse which caused by:
Blood pressure

5. 4
Rules:
 The patient is in sitting position after 5 minutes rest.
 3 parts should be supported: back , feet and the arm.
 The cuff should be at the level of mid sterumcuff ((it should be applied closely to the upper arm, with the
lower border not less than 2 cm from the cubital fossa)).
 It should not be wrapped very tight or very loose.
 The 2 rubber tubes should be adjusted during wrapping the cuff to be in the middle of the cubital fossa.
 The manometer is placed so as to be at the same level as the observer's eye and the cardiac level.
 The diaphragm of the stethoscope is positionedat the lower margin of the cuff over the brachial
artery((medial wall of the cubital fossa)).
 Strat palpatory the auscultatory method.
Technique:
i.Palpatory method:
1) The cuff is inflated gradually until the obliterationpressure: it is the pressure at which the radial pulse is
no longer palpable.
2) Deflate the cuff then do theauscultatory method.
ii.Auscultatory method:
1) inflate the cuff for 30 mmHg above the obliteration pressure.
2) The cuff pressure is slowly reduced to hear the(Korotkoff sounds)(5 phases):
 The first sound to hear is the systolic BP.(Phase 1)
 Then the sound becomes murmurish.(Phase 2)
 Then the sound increases in intensity.(Phase 3)
 Then the sound decreases in intensity.(Phase 4)
 Then the sound disappears which is the diastolic BP.(Phase 5)
The value of the palpatory method is to avoid underestimation of severe systolic hypertension due to the
presence of idiopathic phenomenon called auscultatory gap.
.
Classification of blood pressure levels of the British Hypertension Society
Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
Average 120 80
Hypertension
Grade I (mild) 140-149 90-99
Grade 2 (moderate) 160-179 100-109
Grade 3 (severe) ≥180 ≥110
 In the lowerlimb : the SBP is higher by 10 – 30 mm Hg.
 A difference of 10 mm Hg occurs in 25% of healthy individuals in between both arms.
III.Temperature
The normal range of body temperature (measured orally) of the healthy person is 36.7 º C – 37.3 º C.

6. 5
The three locations normally used in determining the body temperature are:
 The mouth (oral temperature)
 The rectum (rectal temperature)
 The armpit (axillary temperature).
The axillary temperature is 0.5 º C lower than the oral temperature. While the rectal temperature is 0.5 º C
higher than the oral temperature.
A Holding the thermometer.
B Rotating the thermometer.
D temperature on a Celsius (Centigrade scale) thermomete
Measurement of body temperature:
1. Greeting the patient, stand on his right side, introduce yourself and explain to the patient what you
are going to do.
2. Prepare the thermometer tray; mercury thermometer, alcohol, and cotton balls.
3. Wash the hands .
4. Hold the thermometer at the end of the stem, with the fingertips of the right hand at eye level.
5. Rotate slowly the thermometer back and forth until the mercury in the shaft is clearly visible.
6. Wipe the thermometer by cotton balls and alcohol.
7. Shake the thermometer down to 35° C using quick, sharp, downward wrist motions .
8. In case of axillary method;
 Ask the patient to lie in a supine or semi-sitting position.
 Place the bulb of the thermometer in the patient’s clean, dry axilla
 Hold the arm of the patient firmly to the side with the elbow flexed and the hand in contact with the chest.
 Wait at least 3 minutes before removing the thermometer.
 Remove the thermometer from the axilla and dry it by wiping by cotton balls from the stem to the bulb.

7. 6
 Read the thermometer by holding it at eye-level and rotating the stem until the mercury is clearly seen.
 Record the results by adding 0.5 º C to the measured temperature.
9. In case of oral method;
 Ask the patient to open his mouth and raise his tongue.
 Place the bulb of the thermometer on a heat pocket located on the floor of the mouth at the base of the
tongue
 Tell the patient to relax his tongue (thus covering the bulb of the thermometer) and to close his lips firmly
over the thermometer
 Wait at least 3 minutes before removing the thermometer from the patient’s mouth.
 Remove any secretions from the thermometer by wipingby cotton balls from the stem to the bulb.
 Read the thermometer by holding it at eye level and rotating the stem until the mercury is seen clearly.
10. Thanks the patient.
Hypothermia:(<35°C).
Hyperpyrexia is a core temperature >41 °C and may be fatal.
IV. Respiratory rate
 The normal rate of respiration in a relaxed adult is about 14-16 breaths per minute in male.
And 16-18 breaths per minute in female.
 Tachypnea is an increased respiratory rate observed by the doctor.
 Apnea means cessation of respiration.
 Count the RR in complete one minute.
3.Head& neck examination
The face
Malar flush of the face
 erythematous rash on the butterfly area of the face :Mitral stenosis
 Malar pigmentation: pellagra
Eye examination
a) Loss of hair in the outer 1/3 of the eye brows: Myxedema

8. 7
b) Puffiness of lower eye lids:
c) Pallor: “in the conjunctiva”
d) Jaundice: in the sclera
e) Exophthalmos: in Thyrotoxicos
f) Xanthelasma: indicate hyperlipidemia.
Odor of the mouth
a) Fruity (acetone) odor of the mouth is due to: ketoacidosis
b) Odor of ammonia : in hepatic failure and uremia
Tongue examination
a) Cyanosis
b) Coated tongue:
c) Dry tongue:
d) Red glazed tongue:
Toxic face
 Infective endocarditis.
 Septicemia.
 Maignancy.
Neck Veins
 Jugular Venous Pulse (JVP) reflects changes in the right atrium throughout the cardiac cycle.
 Identification:there are 2 jugular veins on each side of the neck:
 External jugular vein: Easy to see, but gives false impression of raised pressure.
 Internal jugular vein: More difficult to see, but is accurate for measurement of pressure & pulsations. Its
examination depends on detection of its pulsations. It runs deeply from the sterno-clavicular joint upwards
& laterally to the angle of the jaw( the vertical line of the neck).
▪ Both can be identified by asking the patient to perform a Valsalva maneuver.
Comment: Neck veins should be examined for:
1. The degree of venous congestion
- Usually, the head of the bed needs slight elevation (45º from the horizontal). However, when the
patient’s venous pressure is increased, the head of the bed may need more elevation up to 60º or even 90º.
In all these positions, the sternal angle remains about 5 cm above the right atrium.
Measuring:
The patient is positioned at about 45° to the horizontal (between 30° and 60°), wherever the top of
the venous pulsation can be seen in a good light. The jugular venous pressure is measured as the vertical
distance between the manubriosternal angle and the top of the venous column. The normal jugular venous
pressure is usually less than 3 cm , which is equivalent to a right atrial pressure of 8 cm when measured
with reference to a point midway between the anterior and posterior surfaces of the chest. The venous
pulsations are not usually palpable (except for the forceful venous distension associated with tricuspid
regurgitation). Venous pressure greater than 3 cm above the sternal angle is considered elevated with the
patient in any position).

9. 8
2. Pulsations : ( pulsating or not?? )
 Normally, the JV pulsations are wavy& consist of 3 positive waves:
 A wave: right atrial contraction while the tricuspid valve is opened. It is a presystolic wave.
 C wave: Upward bulge of tricuspid valve into right atrium due to its sudden closure.
 V wave: right atrial filling during ventricular systole while the tricuspid valve is closed.it is a systolic wave.
and 2 negative waves x and y.
Clinical significance of neck veins:
1) Abnormal pressure: Congested neck veins
 Congested pulsating:
 Congested non-pulsating:
2) Abnormal Pulsations: Abnormal waves
Difference between venous and arterial pulsations
Venous pulsations Arterial pulsations
wavy single
Better seen than felt Better felt than seen
Effect of inspiration Empty with inspiration No effect
Effect of compression of the root of
neck
More congested No effect
Effect of change of posture Significant No effect
4.Examinations of Extremities
I. Edema of the lower limbs
 Examination:
 Press firmly with your thumb for 15-30 seconds behind each medial malleolus, over thedorsum of each
foot & over the shins.
 Look for pitting: a depression in the skin caused by pressure.
 Check for sacral edema in bed ridden patients.
 Palpate the calf muscles for signs of DVT: calf muscles are firm, tense & tender.
 Look for signs of inflammation: redness, hotness or discoloration.
 Types of LL edema:
 Generalized Edema (bilateral edema): cardiac , renal , hepatic and nutritional.
 Localized Edema (unilateral edema): e.g., allergic

10. 9
 Characteristics:
a) Cardiac edema:
i. Occurs in the dependent parts of the body(gravitational):
a. Ankle edema: in ambulant patients.
b. Sacral edema: in bed ridden patients.
ii. Bilateral and equal in both sides.
iii. Always pitting ,firm because tissue fluid is rich in protein.
iv. Edema of lower limbs always precedes appearance of ascites, except in two conditions
in which ascites occurs first “Ascites precox”: Pericardial effusion & constrictive pericarditis
andtricuspid valve disease. Themost important cause of ascites precox is constrictive pericarditis.
b) Renal edema: This occurs in nephritis or nephritic syndromes. Edema occurs first in the eye lids and
is associated with features of renal disease.
c) Hepatic edema: Edema of lower limbs occurs after ascites and is associated with features of liver
disease.
d) Nutritional edema: Edema occurs first in the lower limbs and is associated with features of
nutritional deficiencies.
e) Allergic edema : Edema occurs acutely especially in the lips, eye lids & larynx, but may be
generalized. If it affects the tongue and larynx; it may be life threatening. There is usually positive
family history of edema or other allergies, and the patient himself may have other forms of allergy.
Rapid response of edema to anti- allergic measures is characteristic.
 Pitting or non-pitting edema:
 Non-pitting edema is either due to lymphedema, allergic,myxedema,or inflammatory.
 Pitting edema (pits on pressure) is due to other causes of edema.
 Pathogenesis of edema:
 Increased capillary hydrostatic pressure.
 Increased venous pressure.
 Salt and water retention.
 Hypoalbuminemia.
 Increased capillary permeability
 Resistance to the action of the atrial natriuretic peptide(ANP).
 Impaired lymph drainage.
II. Clubbing of the nails
It is a condition characterized by bulbous enlargement of the distal phalanges of the fingers and toes due to tissue
proliferation of the nail bed secondary to chronic toxemia or hypoxia.
Degrees:
1. First: obliteration of the angle at the nail bed .
2. Second: Parrot beak appearance due to ↑curvature of the nail ( antero-posterior , side to side or both).
3. Third: Drum sticks appearance.
4. Fourth: (pulmonary osteoarthropathy): Drum sticks appearance and swelling of the wrist joint together with
swelling of the lower ends of radius and ulna (periostitis).
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