INTRODUCTION OF PHYSICAL EXAMINATION SIMPLIFIED

1. Points Means to Be Mentioned

CARDIOVASCULAR SYSTEM EXAMINATION
10 points of CVS exams (Macleod)
1.General Observation
- Cyanosis
- Breathlessness
- Distress, demenour
- Sweating
- Body habitus
- Body mass (obesity, weight loss)
- Marfans and other syndromes
2. Hands
- Clubbing
- Splinter hemorrhages
- Skin temperature
- Tremor
3. Pulse and blood pressure
4. Neck
- JVP: height, waveform
- Carotid bruits
5. Face
- Pallor
- Central cyanosis
- Malar flush
- Corneal arcus
- Xanthomata
6. Eyes
- Hypertensive retinopathy
- Diabetic retinopathy
7. Precordium
- Inspect scars, pacemaker sites
- Palpation: apex beat, heaves, thrills
- Auscultation: heart sounds, added sounds, murmurs
8. Lung bases
- Crackles
- Pleural effusion
9. Abdomen
- Hepatomegaly
- Ascites
- Aortic aneurysm
- Sacral edema
- Urine output
10. Legs
- Femoral pulses, bruits, radio-femoral delay
- Popliteal and foot pulses

- Ankle edema
- Leg ulcers
GASTROINTESTINAL SYSTEM EXAMINATION
7 points of GIS exams
1.

General Observation
Body mass (obesity, weight loss)
Hydration
Fever
Distress, pain
Muscle wasting

2.

Hands
Clubbing
Koilonychia
Signs of liver disease
Leukonychia
Palmar erythema

3. Pulse and Blood Pressure

4.

Face
Pallor
Jaundice
Spider Nevi
Parotid Swelling

5. Mouth
Angular stomatitis
Glossitis
6. Neck
Lymphadenopathy
7. Abdomen
Inspections
Scars
Swellings
Distended veins
Palpation
Hepatomegaly
Splenomegaly
Masses
Kidneys
Bladder
tenderness

Percussion
ascites
Auscultation
Bowel sounds
Bruits

8. Groins
Hernias
Lymphadenopathy

9. Perianal/Genitalia
Rectal Examination
Skin tags, hemorrhoids
Rectal bleedings, fecal occult blood
Scrotal Examination
Masses, swellings
10. Legs
edema
pyoderma gangrenosum

RESPIRATORY SYSTEM EXAMINATION

7 points of RS exams
1. General Observation
Respiratory Rate
Body mass (obesity, weight loss)
Fever
Confusion
Distress, demeanour
2. Hands
Clubbing
Peripheral Cyanosis
Tobacco staining
CO2 retention flap
3. Neck
Cervical/scalene lymphadenopathy
Jugular Venous Pressure
Accessory muscle use
4. Face
Central cyanosis
Ptosis / Horners syndrome
5. Chest

Inspection
- Scars
- Deformity: scoliosis, kyphoscoliosis, pigeon chest
Palpation
- Mediastinal shift: tracheal deviation
- Cardiac apex beat
- Expansion
Percussion
- Resonant normal
- Dull collapse or consolidation
- Stony Dul effusion
- Hyperresonant pneumothorax
Auscultation
- Breath sounds: vesicular (normal), bronchial (consolidation)
- Added sounds: crackles (pulmonary edema, fibrosis or infection),
wheeze (asthma, COPD)
6. Abdomen
Hepatomegaly
Sacral edema
7. Legs
Bilateral edema cor pulmonale
Unilateral edema deep vein thrombosis

2. Thorough Analysis of Physical Examination

The Cardiovascular Examination
1. General Examination
Patients general appearance: unwell, breathless, cyanosed, frightened,
distressed?
- Check temperature
- Urinanalysis
1. Hands and Skin
- Look for tobacco staining
- Look for peripheral cyanosis
- Feel the temperature
- Look for splinter hemorrhage
- Look at the palmar aspect for Janeway lesion or Oslers nodes
- Look at palmar and extensor surfaces of the hands for xanthomata
- Look at the entire skin surface for petechiae
- Normal findings:
Hands usually dry at ambient temperature.
Peripheral cyanosis is common in healthy people when the
hands is cold.
One or two splinter hemorrhage are common in healthy
individuals from trauma.

Abnormal findings:
Fever is a feature of infective endocarditis and pericarditis and
may occur after myocardial infarction
Hands may feel warm and sweaty with autonomic stimulation;
while hands may feel cold and clammy with hypotension and
shock
Splinter hemorrhages are found in infective endocarditis and
some vasculitis disorder
Petechial rash (caused by vasculitis), most often present on
the legs and conjunctivae, is transient finding in endocarditis
and can be confused with meningococcal disease.
Janeway lesions, Oslers nodes, nail fold infarcts, and finger
clubbing are uncommon feature of endocarditis
Urinanalysis is necessary to check hematuria (for endocarditis
and vasculitis), glucose (diabetes), and protein (hypertension
and renal disease)
2. Face and eyes
- Look in the mouth for central cyanosis
- At the eyelids for xanthomata
- At the iris for corneal arcus
- Conjunctivae for petechiae
- Examine fundi for features of hypertension, diabetes, roths spots
- Abnormal findings:
3. Arterial pulses
4. Radial pulses
5. Brachial Pulses
6. Carotid Pulse
7. Femoral Pulses
2. Blood pressure
Hypertension
Korotkoff sounds
3. Jugular Venous pressure and waveform
4. The precordium
1. Chest wall abnormalities
2. Apex beat
3. Heart sounds
4. Added sounds
5. Murmurs
5. Lower limb
The Abdomen Examination
1. a [General Inspection]
Patients demenour and general appeareance:
- Is he cachetic, in pain or obese
- Look at his hands for clubbing, koilonycia (spoon-shaped nails)
- Signs of liver disease (leukonychia, palmar erythema)
- Is patient well nourished, obese or thin?
Stigmata for:-

Iron deficiency: Angular cheilitis (painful hacks at the corner of the

mouth) and atrophic glossitis (pale, smooth tongue)
- Folate and vitamin B12 deficiency: tongue has beefy, raw
appearance
- Gluten enteropathy and inflammatory bowel disease: mouth and
throat aphthous ulcers
Examine:
- Cervical, axillary and inguinal lymph nodes: gastric and pancreatic
cancer may spread to cause enlargement of the left supraclavicular
lymph nodes (Troisiers sign).
- More widespread lymphadenopathy with hepatosplenomegaly
suggests lymphoma
Nutritional state
- Record the height, weight, waist circumference and the patients
body mass index
- Note wheter obesity is truncal or generalized
- Look for abdominal striae (which indicate rapid weight gain, previous
pregnancy or rarely cushings syndrome) and loose skin fold (signify
recent weight loss)
Liver disease
- If jaundice not obvious, ask patient to look down and retract upper
eyelid to expose the sclera; look if its yellow in natural light. (do not
confuse the diffuse yellow sclera of jaundice with small yellowish fat
pads (pingueculae) sometimes seen at the periphery of the sclera)
- Signs of chronic liver disease: palmar erythema, spider nevi,
gynecomastia, leukonychia, finger clubbing
- Signs of liver failure: asterixis, fetor hepaticus (mousy odor),
dupuytrens contracture, bilateral parotid swelling

1. b [Inspection]
1. Examine the patient in good light and warm surroundings
2. Position the patient comfortably supine, with the head resting on only one/two
pillows to relax the abdominal wall muscles.
3. Use extra pillows to support a patient with kyphosis or breathlessness
4. Look at the teeth, tongue and buccal mucosa and ask about mouth ulcers
5. Note any smell; alcohol, fetor hepaticus, uremia, melena, or ketones
6. Expose the abdomen; from xiphisternum to the symphysis pubis, leaving the
chest and legs covered
Normal findings: The abdomen is normally flat, or slightly scaphoid and symmetrical
At rest, respiration is principally diaphragmatic; the abdominal wall moves
out and the liver, spleen and kidneys move downwards during inspiration.
The umbilicus is usually inverted.
Normal skin and hair distribution
No visible veins
No abdominal distension

No abdominal scars and stomas

Abnormal findings: Skin

- In older patients, seborrheic warts, ranging in colour from pink to
brown black, and hemangiomas (Campbell de Morgan spots) are
common and normal.
- Note any striae
- Bruising
- Scratch marks
Visible veins
- Abnormally prominent veins on the abdominal wall suggest portal
hypertension or vena caval obstruction.
- In portal hypertension, recanalization of the umbilical vein along the
falciform ligament produces distended veins, which drains away from
the umbilicus: the caput Gedusa. The umbilicus may appear bluish
and distended due to an umbilical varix.
- In contrast, an umbilical herniae, is a distended and everted
umbilicus which does not appear vascular and may have a palpable
cough impulse.
- Dilated tortuous veins with blood flow superiorly are collateral veins
due to obstruction of the inferior vena cava.
- Rarely, superior vena cava obstruction, gives rise to similarly
distended abdominal veins, but which all flow inferiorly
Abdominal distension
- If the abdomen is distended, is this generalized or localized?
- In obesity, the umbilicus is usually shrunken
- In ascites, the umbilicus is flat and everted
- Look tangentially across the abdomen and from the foot of the bed,
for any asymmetry associated with a localized mass, such as
enlarged liver or bladder.
Abdominal scars and stomas
- note any surgical scars or stomas, and clarify what operations have
been undertaken.
- Small infraumbilical incision: usually result of previous laparoscopy
- Puncture scars from the ports, used for laparoscopic may be visible
- Incisional hernia at the site of a scar is palpable, as a defect of
abdominal wall musculature, and becomes more obvious, as the
patient raises the head off the bed or coughs.

2. a [General Palpation]
1. Hands are warm
2. Kneel if the bed is low
3. Show me where is the pain and report if theres pain elicited during palpation
4. Arms by side, to ensure relaxed abdominal wall
5. Use right hand, keep it flat, in contact abdominal wall

6. Observe patients face; any discomfort and pain

7. Begin with superficial palpation; away from any pain
8. Palpate each region, then repeat with deeper palpation
9. Test abdominal muscle tone by light, dipping movement with fingers
10. Describe any mass if found; site, size, surface, shape and consistency, is it
moves on respiration, is mass fixed or mobile?
11. To determine if a mass is superficial and in abdominal wall rather than within
abdominal cavity; ask patient to tense the abdominal muscles by lifting his head.
An abdominal mass will still palpable, whereas intra-abdominal mass will not.
12. Palpation for enlarged organ (liver, gallbladder, spleen and kidneys)
13. Decide whether the mass is an enlarged abdominal organ or separate from
the solid organ.
Normal Findings: A pulsatile mass palpable: in upper abdomen may be normal aortic
pulsation in a thin person, or gastric and pancreatic tumor transmitting
underlying aortic pulsation, or aortic aneurysm
Normal liver: area of dullness to percussion over right anterior chest
between FIFTH RIB AND COSTAL MARGIN.
Normal spleen : area of dullness to percussion posterior to the left midaxillary line, beneath 9TH AND 10TH AND 11TH.
Abnormal Findings: Tenderness: Discomfort during palpation may vary and be accompanied
by resistance to palpation.
- Consider the patients level of anxiety when assessing the severity of
pain and tenderness elicited
- Tenderness in several areas on minimal pressure may be due to
generalized peritonitis, but its more often due to anxiety.
- Severe superficial pain with no tenderness on deep palpation or pain
that disappears if the patient is distracted also suggest anxiety.
- With these exceptions, tenderness usefully indicates underlying
pathology
- Voluntary guarding: voluntary contaction of the abdominal
muscles when palpation provokes pain.
- Involuntary guarding is the reflex contraction of the abdominal
muscles when theres inflammation of the parietal peritoneum.
- If the whole peritoneum is inflamed (generalized peritonitis) due to
the perforated viscus, the abdominal wall no longer moves with
respiration; breathing becomes increasingly thoracic, and the
anterior abdominal wall muscles are held rigid (board-like rigidity)
Site of tenderness is important. Tenderness in the:- epigastrium suggest peptic ulcer
- right hypochondrium; cholecystitis
- left iliac fossa; diverticulitis
- right iliac fossa; appendicitis or Chrons ileitis
Rebound tenderness is a sign of intra-abdominal disease but not

necessarily of parietal inflammation (peritonism). Ask the patient to cough

or gently percuss the abdomen to elicit any pain or tenderness, rapidly
removing your hand after deep palpation increases the pain.
Palpable mass.
- A pathological mass can usually be distinguished from palpable
feces, as the feces are indentable and may be disappear after
defecation.
- A hard subcutaneous nodule palpable at the umbilicus may indicate
metastatic cancer (Sister Mary Josephs nodule)

2. b [Palpation for enlarged organs:-]

1. Hepatomegaly
- place your hand on the skin of right iliac fossa (RIF)
- point your fingers upwards, your index and middle fingers lateral to rectus
muscle (so that your fingers lie parallel to the rectus sheath. Look in Macleod Fig
8.16.)
- ask the patient to breathe in deeply through the mouth
- feel for the liver edge; as it descends on inspiration
- move your hand progressively up the abdomen, 1cm at a time, between each
breath the patient takes, until you reach the costal margin, or detect the liver
edge.
- the liver may be enlarged or displaced downwards by hyperinflated lungs. Fig
8.17
- describe liver edge: size, surface (smooth or irregular), edge (smooth or
irregular), consistency (soft or hard), tenderness, is it pulsatile
Normal findings for liver exams:You may feel the liver edge below the right costal margin. Other normal findings
may include:- aorta may be palpable, as a pulsatile swelling above the umbilicus.
- lower pole of the right kidney may be palpable in the right flank
- faecal scybala, may be palpable, In sigmoid colon in the left iliac fossa
- full bladder, arising out of the pelvis, may be palpable in the suprapubic region.
Abnormal findings for liver exams: Hepatic enlargement can result from chronic parenchymal liver disease from
any cause.
The liver is enlarged in early cirrhosis, but often shrunken in advanced cirrhosis.
- Fatty liver (hepatic steatosis) can cause marked hepatomegaly.
- Metastatic tumour produce hard and irregular hepatic enlargement.
- Enlarged left lobe may be felt in epigastrium or even in left hypochondrium.
- An audible bruit may be heard over the liver in hepatocellular cancer and
sometimes in alcoholic hepatitis.
- In right heart failure, the congested liver usually soft and tender; a pulsatile liver
indicates tricuspid regurgitation

- A bruit over the liver may be heard in acute alcoholic hepatitis, hepatocellular
cancer and arteriovenous malformation.
Resonance below the fifth intercostal space suggest
- emphysema, or occasionally
- the interposition of the transverse colon between the liver and the diaphragm
(Chilaiditis sign)
Palpable distension of the gallbladder has a characteristic globular shape. Its
rare, and results from either:- obstruction of cystic duct, or as in a microcele, or empyema of the gallbladder,
or
- obstruction of the common bile duct (providing the cystic duct is patent), as in
pancreatic cancer.
- In gallstone disease the gallbladder may be tender but impalpable because of
fibrosis of the gallbladder wall

2. Splenomegaly
- Place your hand over the umbilicus. Fig 8.18
- Keep your hand stationary and ask the patient breath in deeply through mouth
- feel the splenic edge as it descends on inspiration
- Move your hand diagonally upwards, towards the left hypochondrium, 1cm at a
time, between each breath the patient takes.
- Feel the left costal margin along its length, as the position of the spleen tip is
variable.
- If you cannot feel the splenic edge, ask the patient to roll towards you on his
right side, and repeat the above.
- Palpate with your right hand, placing your left hand behind the patients left
lower ribs, pulling the ribcage forward Fig 8.18B
- Feel along the left costal margin and percuss over the lateral chest wall, to
confirm or to exclude the presence of splenic dullness.
Differentiating palpable spleen from the left kidney
- Mass (spleen) is more regular and smooth in shape
- Mass descends in inspiration (travels superficially and diagonally)
- Able to feel deep to the mass
- Theres a palpable notch on medial surface
- No bilateral masses
- Percussion is not resonant over the mass
- The mass extends beyond the midline sometimes.
Normal findings for spleen exams :The normal spleen lies beneath the 9th and 11th ribs in the left mid-axillary line
Abnormal findings of spleen exams:- The spleen has to increase threefold before it become palpable, so a palpable
spleen always indicate splenomegaly.

- It enlarges from under the left costal margin down and medially towards the
umbilicus Fig 8.17B
3. [Percussion]
1. Ask the patient to hold his breath in full expiration
2. Percuss downwards, from the right fifth intercostal space in the
midclavicular line, listening for dullness that indicates the upper border of
liver
3. Measure the distances in centimeters below the costal margin in the
midclavicular line, or from the upper border of dullness to the palpable liver
edge
4. To feel for gallbladder tenderness (in cholecystitis):
- Ask the patient to breathe in deeply and gently palpate the right
upper quadrant of the abdomen in midclavicular line.
- As the liver descends, the inflamed gallbladder contracts the
fingertips, causing the pain and sudden arrest of inspiration
(Murphys sign)
Percussion for Ascites
Ascites: is accumulation of intraperitoneal fluid.
Causes of ascites:- intra-abdominal malignancy
- chronic liver disease
- severe heart failure
- nephrotic syndrome
- hypoproteinemia
Sequence:1. Shifting dullness
- patient supine
- percuss from the midline, out to the flanks. Note any changes from resonant to
dull, along with areas of dullness and resonance. (from resonant to dull).
- Keep finger on site of dullness in the flank and ask patient to turn on to his
opposite side (to test for ascites)
- pause for 10 seconds, to allow any ascites to gravitate, then percuss again.
- if the area of dullness now resonant, shifting dullness is present.
2. Fluid thrill
If abdomen is tensely distended, and if you are not sure whether ascites is
present, test for fluid for a fluid thrill.
- Place the palm of your left hand against the left side of the patients abdomen
and flick a finger of your right hand against the right side of the abdomen.
- if you feel a ripple against your left hand, ask an assistant or the patient to place
the edge of his hand on the midline of the abdomen
- This action will prevents transmission of the impulse via the skin rather than
through the ascites. If you still feel a ripple against your left hand, a fluid thrill Is
present (only detected in gross ascites)
4. [Auscultation]
- Patient supine

- Place your stethoscope diaphragm to the right umbilicus, and do not move it.
- Listen for up to 2 minutes, before concluding that bowel sounds are absent.
- Listen above the umbilicus over the aorta for arterial bruit
- Now listen 2-3 cm above and lateral to the umbilicus, for renal artery stenosiss
bruits
- Listen over the liver for bruits
- A succussion splash sounds like half-filled water bottle being shaken. Explain the
procedure to the patient, then shake the patients abdomen, by lifting him with
both hands under his pelvis.
Normal findings
- Bowel sounds are gurgling noises, from the normal peristaltic activity of the gut.
- Normally occur every 5-10 seconds, but the frequency varies
Abnormal findings
- absence of bowel sounds implies paralytic ileus or peritonitis
- In intestinal obstruction, bowel sounds occur with increased frequency and
volume, and have a high pitched, tinkling quality.
- Bruits suggest an atheromatous or aneurysmal aorta or superior mesenteric
artery stenosis.
- A friction rub, which sounds like rubbing your dry fingers together, may be heard
over the liver(perihepatitis) or spleen (perisplenitis).
- Audbile splash more than 4 hours after the patient has eaten or drunk anything,
indicates delayed gastric emptying (ex: pyloric stenosis).
The Respiratory Examination
GENERAL EXAMINATION
EXAMINATION SEQUENCE
NORMAL FINDINGS
ABNORMAL FINDINGS
STRIDOR
CYANOSIS
BLOOD PRESSURE
SKIN APPEARANCE
HANDS
CLUBBING
DISCOLORATION OF THE FINGERS AND NAILS

NECK
JUGULAR VENOUS PRESSURE
NECK NODES
THORAX
CHEST SHAPE
SKIN
PALPATION
CHEST EXPANSION
PERCUSSION
AUSCULTATION
ADDED SOUNDS
VOCAL RESONANCE