RESPIRATORY EXAM

1) Wash hand 6) POSTERIOR CHEST

2) Introduce and seek permission. a. Inspection
3) General Examination : b. Palpation
a. Body mass? alert, conscious , able to i. Lymph nodes- submental,
speak in full sentence, not in distress, submandibular, preauricular,
cachexic (muscle wasting) , postauricular,occipital,
breathlessness, stridor, scar?, cervical, supraclavicular
deformity?, use of accessory mucle?, ii. Chest expansion
b. surrounding : nasal prongs? Chest iii. Tactile fremitus
tube? Oximetry ? Nebulizer machine? c. Percussion
Cannula ? AV fistula? Oxygen tank? i. Upper,middle,lower and
4) Peripheral Inspection lateral
a. Tremor – fine tremor ( beta-agonist/ d. Auscultation
theophylline bronchodilators drug) , i. Vesicular breath sounds
flapping tremor (Co2 retention) ii. Vocal resonance
b. Hands Palm = Tobacco stain ? iii. Whispering pectoriloquy
peripheral cyanosis ? Pallor? finger iv. Crackles
clubbing? *loss of normal angle 7) Sacral edema
between nail and nail bed/increase 8) Pedal edema
nail bed fluctuation/increase bulk of 9) Thank the patient
soft tissue over the terminal 10) To complete my examination, I would like to
phalenges/ increase nail curvature perform pulse oximetry , peak flow rate,
later stages* capillary filling? spirometry, arterial blood gas, chest x-ray,
c. Arm BP and RR bronchoscopy.
d. Eyes- pallor or cyanosis
e. Mouth – central cyanosis
f. JVP Palpation
g. Trachea deviation and tracheal tug
5) Chest examination
a. Inspection : shape of chest ( AP-
Lateral diameter) , lesion?
thoraconectomy scar,
*pigeon chest(pectus carinatum)
*funnel chest(pectus excavatum)
*barrel shape
b. Palpation :
i. Chest expansion – symmetry ?
ii. Tactile fremitus
c. Percussion
i. Apex, Middle, Lower and
Lateral
d. Auscultation
i. Vesicular/ bronchial
breath sounds
ii. Vocal resonance
iii. Whispering fremitus

Nurul Dhuhayati Othman

 Patient is a young/elderly male/female of
small/medium/large build , was alert and
conscious and able/unable to speak in full
sentence.
 Patient was lying down comfortably/
uncomfortably propped up at 45degrees with no
signs of cachexic and respiratory distress.
 Patient has (no) chest wall deformities and (no)
scars. Patients hands have (no) signs of cyanosis,
pallor and clubbing.
 Patients RR is ____ and PR is ______.
 Patients eyes show (no) signs of Pallor and
cyanosis.
 Patient has bad/good oral hygiene.
 Patient JVP is not raised/raised.
 Lymph nodes were non-tender/tender on
examination.
 Patients trachea is centrally located/deviated.
Tracheal tug was absent/present.
 Patient shows normal/decreased chest expansion.
 Percussion was resonant/dull on the upper,
middle and lower lung lobes.
 On Auscultation, Patient exhibited
Vesicular/Bronchial breath sounds.
 There was normal/decreased vocal fremitus.
There was absent/present whispering
Pectoriloquy.
 Wheezing was absent/present.
 Crepitations were absent/present.
 Pedal and sacral edema was absent/present.

Nurul Dhuhayati Othman

CARDIOVASCULAR EXAM
1) Wash hand
2) Introduce and seek permission.
3) General Examination :
a. Unwell? Breathless? Cyanosed?
Frightened ? Distress? scar? Body
mass? alert, conscious , able to speak
in full sentence, breathlessness,
deformity?cachexic? Marfan
syndrome, Down syndrome, turner’s
syndrome
b. surrounding : ECG machine?nasal
prongs? Chest tube? Oximetry ?
Nebulizer machine? Cannula ? AV
fistula? Oxygen tank?
4) Peripheral Inspection
a. Hands Palm = clubbing? Splinter
haemorrhage, osler’s nodes, janeway
lesion, tendon xantomata, Tobacco
stain ? peripheral cyanosis ? Pallor?
finger clubbing? *loss of normal angle
between nail and nail bed/increase
nail bed fluctuation/increase bulk of
soft tissue over the terminal
phalenges/ increase nail curvature
later stages* capillary filling?
b. Radial pulse (rate, rhythm, volume)
and RR
c. Collapsing pulse
d. Radio-radio delay?
e. BP
f. Eyes- xanthelasma, corneal arcus,
conjuctival pallor
g. Mouth – central cyanosis and dental
carries
h. JVP , hepatojugular reflex
5) Precordium examination
a. Inspection :
i. Shape of chest : pectus
excavatum, pectus carinatum
ii. Scar : midsternotomy scar
(bypass) , submammary
scar(mitral valvotomy),
infraclavicular
scar(pacemaker, defibrillator)
iii. Visible pulsation?
b. Palpation : apex beat *character* ,
heaves (heel of hands), thrills
(palpable vibration)
c. Auscultation – pulmonary, aortic,
mitral, tricuspid
i. Time murmur
ii.Added sound ?
iii.Murmur
iv. VSD- lower left sternal border
v. Pulmonary valve murmur –
upper left sternal border
vi. Aortic stenosis – upper right
sternal border
vii. Carotid bruits/ aortic stenosis
viii. Left axilla – mitral regurge
radiation
ix. Mitral stenosis @apex
x. Left manuever (opening snap)
xi. Sit forward
xii. Aortic regurge @left sternal
edge @3rd / 4th intecostal
spaces
6) POSTERIOR CHEST
a. Lung basal – crackles
7) Sacral edema
PERIPHERAL VASCULAR EXAMINATION (flat)
1) Abdomen
a. Inspect abdomen : visible pulsation ,
surgical scars
b. Palpation : abdominal aorta *above
umbilicus*
c. Auscultate – abdominal aorta bruit to
stenosis, renal arteries bruit
bilaterally
2) Lower limb
a. Inspect lower limb : ischemic, venous
insufficiency, colour change?loss of
hair surgical scars ?temperature
different? Ulceration.
b. Inspect toes and heels
c. Palpate femoral pulses
d. Auscultate
3) Popliteal pulses
4) Posterior tibial pulse
5) Dorsalis pedis pulse
6) Buerger’s test
7) Pedal edema
8) Thank the patient
9) To complete my examination, I would like to
perform pulse Full blood count, urinalysis,
blood glucose, lipid profile,
electrocardiogram, echocardiogram, chest x-
ray, coronary angiography.
Nurul Dhuhayati Othman
 Patient is a young/elderly male/female of
small/medium/large build , was alert and
conscious and able/unable to speak in full
sentence.
 Patient was lying down comfortably/
uncomfortably propped up at 45degrees with no
signs of distress or breathlessness.
 Patient has (no) chest wall deformities and (no)
scars. Patients hands have (no) signs of cyanosis,
splinter haemorrhage, Osler’s nodes, janeway
lesion, xantomata and finger clubbing.
 Patients radial pulse was ___ bpm,
(regular/irregular) rhythm , (good/ low ) volume.
 There was (no) collapsing pulse or (no) radial-
radial delay.
 BP was ___/___ mmHg.
 On examination of the face, Patients eyes show
(no) xanthelasma, corneal arcus, conjuctival pallor
and Patient has bad/good oral hygiene.
 Patient JVP is not raised/raised when doing
hepatojugular reflex.
 Moving on to precordium, there was no obvious
middle sternoctomy scar, and the shape of the
chest was normal/ funnel/pigeon chest. (no)
visible pulsation were seen.
 Patients apex beat was palpable in the
midclavicular line of the 5th intercostal space.
 Thrills and heaves were present/absent
@________
 On Auscultation, first and second heart sound was
heard, (no) additional heart sounds and (no)
murmur was heard//////Patient exhibited a
loud/soft murmur @ __________
 Auscultation on the back shows present/absent of
bibasal crackles
 Sacral edema and pedal edema (present/absent)

Nurul Dhuhayati Othman

GASTROINTESTINAL SYSTEM EXAM d. Auscultation
1) Wash hand i. @ right of umbilicus for bowel
2) Introduce and seek permission. sound ( listen for 2 mins)
3) General Examination : ii. Above the umbilicus (arterial
a. Normal/ obese? Abdominal striae? bruits
alert, conscious , able to speak in full iii. Liver ( bruits)
sentence, not in distress, cachexic iv. Kidney
(muscle wasting) , breathlessness, e. POSTERIOR
stridor, scar?, deformity?, use of i. Lymph node
accessory mucle?, ii. Sacral edema
b. surrounding : nasal prongs? Chest f. Sacral edema
tube? Oximetry ? Nebulizer machine? 8) Thank the patient.
Cannula ? AV fistula? Oxygen tank? 9) Hand rub
4) Peripheral Inspection 10) To complete my examination, I would like to
a. Tremor- flapping tremor perform per-rectal examination, hernia orifice
b. Hands Palm = leuconychia, examination, external genitalia examination,
koilonychias? finger clubbing? Palmar temperature chart, endoscopy.
erythema? Spider naevi? Dupuytrn’s
contracture?Tobacco stain ?
peripheral cyanosis ? Pallor? Needle
tracks?
c. Eyes- jaundice ,pallor or cyanosis
d. Mouth – angular stomatitis/central
cyanosis, ulcers
e. Tongue – dehydration
5) Spider naevi @ upper half of body
6) Lying supine
7) Abdomen examination
a. Inspection :
i. shape (flat, slightly scaphoid
and symmetrical),
ii. look for scars
(appendicectomy scars left
inguinal,suprapubic, lower
midline),
iii. distention (localized or
generalized)
iv. umbilicus (inverted, flat, or
sunken)
v. pulsation (visible veins?
Caput medusae? Herniation?
b. Palpation : *observe patient’s face*
i. Light palpation
ii. Deep palpation
iii. Liver (move up)
iv. Spleen
v. Kidney
c. Percussion
i. Liver border
ii. Spleen
iii. Ascites – shifting dullness,
fluid thrills(gross only)
Nurul Dhuhayati Othman
 Patient is a young/elderly male/female of
small/medium/large build , was alert and
conscious and able/unable to speak in full
sentence.
 Patient was lying down comfortably/
uncomfortably in supine position with the hands
at the sides with no signs of cachexic and
respiratory distress. No abdominal striae was
noted.
 Patient has a BMI of ____ kg/m2
 Patients hands have (no) signs of flapping
tremor,leuconychia, koilonychias, finger clubbing,
palmar erythema,was not seen and dupuytren’s
contracture was absent/present.
 Patients eyes show (no) signs of Pallor/ jaundices.
 Patient’s mouth does not show any angular
stomatitis, tongue showed dehydration/ulcer?
 Patient’s upper half of body showed
present/absent of spider naevi
 On inspection of the abdominal, the shape was
normal/ asymmetry , the abdominal wall was/
(not)distended, umbilicus was
(inverted/flat/sunken)
 (no) visible veins and caput medusa seen.
 No scars were seen and no herniation
 On palpation, the abdomen regions were soft and
tender. Liver border and spleen is palpable and
kidney was not balloatable.
 Moving on to percussion, the liver and spleen
were dull on percussion, no hepatomegaly and
splenomegaly noted
 Ascites was (present/absent). Shifting dullness
was positive/ negative and the fluid thrills was
present/absent.
 On Auscultation, bowel sound could be heard and
there was no bruits.
 Lymph nodes were non-tender/tender on
examination.
 Pedal and sacral edema was absent/present.

Nurul Dhuhayati Othman

CENTRAL NERVOUS SYSTEM EXAMINATION

Motor Cranial nerves

1) Hand rub 1) Olfactory – smell
2) Introduce, seek permission 2) Optic nerve
3) Inspection a. visual acuity
i. Proximal and distal limb b. Visual field
ii. Symmetry 3) Oculomotor, trochlear, abducens
iii. Scars a. Ocular movement
iv. Fasciculations / involuntary b. Pupil dilatation
movements 4) Trigeminal
4) TONE – make sure patients go floppy(relaxed) a. Sensory – close eyes, say yes , touch
i. Upper limb - Flex and extend wrist, using cotton wool tip/ neurological
elbow and shoulder pin
ii. Lower limb – roll, flex , extend, ankle b. Motor – clench teeth, feel masseter
clonus and open jaw, resist, jaw jerk
5) POWER – 5) Facial –
i. Shoulder abduction, adduction a. Inspect : symmetry, any spontaneous
ii. Elbow extension, flexion movement
iii. Finger adduction, extension b. Raise eyebrow
iv. Grip strength c. Wrinkle
v. Hip flexion , extension d. Smile and show teeth
vi. Knee flexion, extension e. Puff
vii. Ankle dorsiflexion, plantar flexion f. Close eyes, resist
viii. Great toe extension 6) Vestibulocochlear nerve
ix. Ankle eversion, inversion a. Weber’s test (forehead)
6) REFLEX b. Reinne’s test
i. Supinator jerk 7) Glossopharyngeal & vagus
ii. Biceps a. Asses speech
iii. Triceps b. Say Ahhh~
iv. Knee c. Ask patient to cough
v. Ankle jerk 8) Accessory nerve
7) COORDINATION a. Inspect sternocleidomastid and
i. Finger to nose test trapezius muscle
ii. Heel to shin test b. Shrug shoulder, resist
iii. Rapid alternating movements c. Turn to left resist (hand at the chin)
9) Hypoglossal
a. Inspect tongue (wasting,
fasciculations / involuntary
Sensory
movement)
1) Light touch b. Put out tongue outside, move side to
2) Superficial pain side
3) Temperature c. Place tongue inside @ cheek, push
4) Vibration the cheek
5) Joint position sense d. Asses speech – yellow lorry
6) Stereognosis

Nurul Dhuhayati Othman

 SIGN AND CAUSES
SYMPTOMS
Gait Spastic hemiparesis – UMNL stroke
Steppage gait – LMNL
Sensory/ cerebellar ataxia – polyneuropathy, syphilis
Pakinsonian gait – lesion in basal ganglia
Tall stature Marfan syndrome, hypogonadism, pituitary gigantism
Cyanosis Central –
1. decreased conc. Of inspired oxygen(high altitude), hypoventilation, Lung
disease( COPD with cor pulmonale, massive pulmonary embolism), right to
left shunt (congenital heart disease)
2. polycythemia
3. haemoglobin abnormalities
peripheral cyanosis –
1. all causes of central cyanosis
2. exposure to cold
3. reduced cardiac output
4. arterial/ venous obstruction
Shock 1. hypovolumia ( external fluid loss, ascites)
2. cardiac – Myocardial infarction, acute mitral regurge, cardiac tmponade, massive
pulmonary embolus, sepsis,
Spinter Infective endocarditis, vasculitis
haemorrhages
Abnormal melanin Underproduction : vitiligo, albinism, hypopituitarism
production Overproduction : addison’s disease, cushing’s syndrome
Leuconhychia Hypoalbuminemia
(whitening)
Koilonychias (spoon- Iron deficiency, fungal infections, Reynaud’s disease
shaped nails)
Clubbing CVS :Congenital heart disease , infective endocarditis
RESPIRATORY :lung cancer, bronchiectasis, lung abscess, empyema

UNCOMMON : cystic fibrosis, cirrhosis, Inflammatory bowel disease, celiac disease,

thyrotoxicosis,
Lymphadenopathy Generalised Localised :
1. viral – Cytomegalo virus, HIV 1. infective
2. bacterial – syphilis, brucellosis 2. malignancy
3. protozoal- toxoplasmosis
4. malignancy- lymphoma, ALL, CLL
5. inflammatory – SLE, sarcoidosis
Bradycardia Regular : athletes, sleep, drugs(beta-blockers,digoxin), hypothyroidism, hypothermia,
raised intracranial pressure, complete heart block,

Irregular : atrial fibrillation

Tachycardia Regular : xercise, pain, fever, hyperthyroidism, drugs( salbutamol vasodilators)

Ireegular : atrial fibrillation, atrial flutter, SVT, Ventricular tachycardia

Irregular pulses Sinus arrhythmia, atrial extrasystoles, ventricular extrasystoles, atrial fibrillation, atrial
flutter, second degree heart block
Atrial fibrillation Hypertension, heart failure, myocardial infarction, thyrotoxicosis, alcohol related heart
disease, mitral valve disease
Increased pulse Physiological : exercise, pregnancy, increased environmental temperature
volume Pathological : hypertension, fever, thyrotoxicosis, anaemia, aortic regurge, peripheral
vascular disease.
Pulse character Collapsing pulse – severe aortic regurgitation, anaemia, thyrotoxicosis, systemic
hypertension, Beri-Beri, Patent Ductus Arteriosus, severe excersise, mild tachycardia,
Paget’s disease, aortic incompetence, pregnancy (3rd trimester)
Nurul Dhuhayati Othman
 Slow-rising pulse – severe aortic stenosis
Pulses bisferians- aortic regurge, aortic stenosis
pulses alternans- advanced heart failure
pulsus paradoxus- cardiac temponade, constrictive pericarditis
Generalized edema Fluid overload – heart failure, renal disease
Hypoproteinemia- reduced oncotic pressure, increased hydrostatic pressure, increased
capillary permeability, lymphatic obstruction
Localized edema Venous – increased venous pressure -> increase hydrostatic pressure within capillaries
Lymphatic - obstruction, imparaired
Inflammatory – infection or injury
Allergic
Raised JVP Fluid overload, acute pulmonary embolism, COPD, cor pulmonale,Pulmonary edema,
massive pulmonary embolus, Right ventricular failure, tricuspid stenosis / regurgitation,
pericardial effusion/ constrictive pericarditis, superior vena cava obstruction (lung
cancer)
Flapping tremor Co2 retention
Bronchial breath Common :Lung consolidation
sounds Uncommon : lung collapsed, pulmonary fibrosis
Crackles Early – small airways disease
Middle – pulmonary edema
Late – pulmonary fibrosis, pulmonary edema, bronchial secretions in COPD, pneumonia,
lung abscess
Biphasic – bronchiectasis
Abdominal Female, fat, flatus, feaces, fluid, fetus, functional
distention
Ascites Common : Hepatic cirrhosis with portal hypertension, intra-abdominal malignancy with
peritoneal spread
Uncommon : hepatic vein occlusion, constrictive pericarditis, hypoproteinemia,
pancreatitis
Upper GI bleeding Peptic ulcer, Mallory-weiss oesophageal tear, gastritis, oesophageal varices
Rectal bleeding Haemorrhoids, anal fissure, colorectal polyps, IBD, complicated diverticular disease
Jaundice 1. Increased bilirubin production: haemolysis
2. Impaired bilirubin excretion :
a. Congenital :
b. Hepatocellular – viral hepatitis, cirrhosis, drugs
c. Intrahepatic cholestasis
d. Extrahepatic cholestasis

Palmar erythema Excess oestrogen associated with reduced hepatic breakdown of sex streoids
Spider naevi Excess oestrogen associated with reduced hepatic breakdown of sex streoids
Hepatomegaly 1. Chronic parenchymal liver disease- alcoholic liver disease, hepatic stenosis, viral
hepatitis
2. Malignancy – primary hepatocellularcancer, secondary metastatic cancer
3. Right heart failure
4. Haematological disorders- lymphoma, leukemia, polycythemia, myelofibrosis
5. Rarities – amyloidosis, sarcoidosis
Splenomegaly 1. Haematological disorders – lymphoma, haemolytic anaemia, polycythemia rubra
vera
2. Portal hypertension –
3. Infection – malaria, tuberculosis, salmonellosis, bacterial endocarditis
4. Rheumatological condtions – SLE
Hepatosplenomegaly Lymphoma, myeloproliferative didease, cirrhosis with portal hypertension, amyloidosis,
sarcoidosis

Nurul Dhuhayati Othman