Anda di halaman 1dari 10


Junior Internship A.Y. 2013 – 2014


1. Room/Bed # 9. Birth date 17. Provincial address

2. Hospital # 10. Birth place 18. Contact number
3. Admission # 11. Educational attainment 19. Date and time of admission
4. Attending Physician/s 12. Civil status 20. Date and time of interview
5. Resident/s-in-Charge 13. Nationality 21. Informant
6. Name 14. Religion 22. Reliability
7. Age 15. Occupation
8. Sex 16. Current address


1. Immunizations
• Why did the patient seek care? Vaccine Schedule Route Adverse effects
ID Abscess at site,
<12 months: 0.05 ml Birth
HISTORY OF PRESENT ILLNESS (Deltoid) Axillary lymphadenopathy
> 12 months: 0.1 ml
Headaches, upper respiratory tract
Birth, 4, 10 w IM infections,
1. Complete description of first symptoms Hepatitis B
or (UO Stuffy nose, sore throat, joint pain,
• Provokes – causative, relieving, exacerbating factors 0.5 ml
6, 10, 14 w thigh) Abdominal pain, cough, nausea,
• Quality diarrhea, fever
− Pain: sharp, dull, stabbing, burning, crushing IM Fever up to 72 hours,
DTP (UO Restlessness and irritability,
• Radiates thigh) Local reaction
− Primary location OPV PO Paralysis
6, 10, 14 w
− Area where it radiates Hib IM
Low grade fever
Pain and swelling
− Localization PCV 0.5 ml -
• Severity (0 – 10)/Intensity/Progression Rotavirus 0.5 ml
Intussusception if 1st dose > 15 mon
• Time 9 months
Fever +/- rash after 5 – 12 days
− Onset Measles 0.5 ml (6 months if SC
− Duration Measles – fever
− Persistence 1 year Mumps – parotid gland swelling
MMR 0.5 ml SC
− Number of occurences Booster: 4-6y Rubella – arthritis/ arthralgia, post-
auricular lymphadenopathy
2. Medications (include dosage)
2. Regular medical visits
3. Results of previous laboratory work-up
3. Regular blood test/X-rays
4. Results of previous ancillary procedures
• Results
5. State of health just before onset of problem
• When did you last feel well?
6. What led the patient to seek consult?
Hypertension Allergy Gout/arthritides
Heart disease Asthma Stroke
PAST MEDICAL HISTORY Diabetes mellitus Tuberculosis Seizures
1. Illnesses Thyroid disease Blood dyscrasias Cancer
Hypertension Allergy Gout/arthritides Others:
Heart disease Asthma Stroke
Diabetes mellitus Tuberculosis Seizures
Thyroid disease Blood dyscrasias Cancer
1. Habits
2. Allergies
• Smoking history
• Food
• Alcohol
• Environmental exposures
• Substance use/abuse
• Adverse drug reactions
2. Nutrition
3. Medications
• Diet
• Current
• Source of water
• Frequently
3. Sleep pattern
• Herbal
4. Exercise
4. Previous hospital admission
5. Living arrangement
5. Previous injury
6. Source of income
6. Previous surgery
7. Support system
7. Previous blood transfusion
1. Menarche age/Menopause age
2. Menstrual flow
• Interval
• Duration
• Amount
• Symptom (Dysmenorrhea)
3. LMP
4. PMP

SEXUAL HISTORY • Orthopnea (paggamit ng dalawang unan kapag
1. Coitarche natutulog)
2. # of sexual partners • Hemoptysis (umubo at dumura ng dugo)
3. Symptoms (Dyspareunia, post coital bleeding) • Paroxysmal nocturnal dyspnea (nagi-gising sa gabi dahil
sa hirap huminga)
1. Obstetrical score • Pain (pananakit ng dibdib)
• Gravidity, Parity • Palpitation (nararamdaman ang pagtibok ng puso)
• Term, Preterm, Abortion, Living • Edema (pamamanas)
2. Details of previous pregnancy 10. LYMPHATIC
• Year, manner, and outcome of delivery • Lymphadenopathy (pamamaga/bukol sa leeg o singit)
3. Family planning method/s • Lymph node pain (masakit ang namamaga)
4. Prenatal check-ups for current pregnancy 11. GASTROINTESTINAL
• Pain (pananakit sa tiyan)
FAMILY HISTORY • Nausea (pagkahilo, nasusuka)
1. Allergy • Vomiting (pagsusuka)
2. Asthma • Anorexia (kawalan ng gana kumain)
3. Tuberculosis • Dysphagia (nahihirapan lumunok)
4. Gout/Other arthritides • Heartburn (pananakit ng dibdib)
5. Blood dyscrasias • Excessive gas (hangin sa tiyan)
6. Cancer • Dyspepsia (masamang pakiramdam kapag busog)
7. Diabetes mellitus • Bowel movements (gaano kadalas ang pagdudumi)
8. Heart diseases • Change in stool: (pababago sa dumi)
9. Hypertension − Color (kulay)
10. Stroke − Quantity (dami)
11. Mental illness − Consistency: solid or liquid
12. Others (buo o matubig)
• Hematochezia (dumi na may kasamang mapulang
1. SKIN • Melena (dumi na kulay itim)
• Changes in skin, nails, hair 12. GENITOURINARY
• Lesions • Problem in urination (problema sa pagihi)
• Rashes (pamamantal) • Changes in urine: (pagbabago sa ihi)
• Soreness (pamamaga) − Color (kulay)
• Lumps (bukol) − Quantity (dami)
• Itching (pangangati) − Frequency (kadalasan)
2. EYES • Dysuria (masakit ang pagihi)
• Visual acuity (paningin) • Urinary retention (pakiramdam na puno ang pantog kahit
• Visual specks (dumi) matapos umihi)
• Flashing light (bumubugsong ilaw) • Hesitancy (nahihirapan simulan ang ihi)
• Pain (pananakit) • Urinary incontinence (inboluntaryong naihi – pagtawa,
• Itching (pangangati) nabahing, o pagubo)
3. EARS • Force of stream (humihina ang lakas ng pagihi, pinipilit
• Hearing (pandinig) ang pagihi)
• Pain (pananakit) • Dribbling (tumutulo kahit tapos na umihi)
• Dizziness (pagkahilo) • Nocturia (nagigising ng madalas dahil kailangang umihi)
• Discharges (kakaibang lumalabas) • Flank pain (pananakit ng likod)
• Tinnitus (kakaibang naririnig) 13. MUSCULOSKELETAL
4. NOSE • Difficulty in ambulation (nahihirapang gumalaw,
• Pain (pananakit) maglakad)
• Difficulty breathing (hirap sa paghinga) • Joint pain (pananakit ng kasukasuhan)
• Cold/flu (sinisipon) 14. NEUROLOGIC
• Pain on sinuses (pananakit sa mukha) • Headache (pananakit ng ulo)
• Epistaxis (dumudugo ang ilong) • Dizziness (pagkahilo)
• Discharges (kakaibang lumalabas) • Impaired memory (nakakalimot)
5. MOUTH • Loss of consciousness (nahimatay)
• Pain/ Sore tongue (pananakit) • Tingling sensation (kakaibang pakiramdam sa isang parte
• Lesions (sugat) ng katawan)
• Bleeding gums (dumudugo ang gilagid) • Seizures (pangangatog)
• Change of taste (nagiba ang panlasa) • Hallucinations (nakakakita ng mga bagay na hindi totoo)
6. THROAT • Sensory perversion (pagbabago sa paningin, pandinig,
• Sore throat (nangangati ang lalamunan) pangamoy, panlasa)
• Cough (inuubo) 15. HEMATOLOGIC
• Phlegm (plema) • Pallor (namumutla)
• Trouble speaking (nahihirapan magsalita) • Easy fatigability (madaling mapagod)
7. CHEST • Spontaneous bleeding (pagdugo)
• Pain (pananakit) 16. ENDOCRINE
• Lumps (bukol) • Polyphagia (sumusobra ang pagkain)
• Discharge from the breast (kakaibang lumalabas mula sa • Polyuria (dumami ang pagihi)
suso) • Heat intolerance (mabilis mainitan)
8. RESPIRATORY • Cold intolerance (mabilis lamigin)
• Dyspnea (hirap sa paghinga)
Junior Internship A.Y. 2013 – 2014

1. Makes an accurate general survey and • General appearance, posture (relaxed, rigid, restless), grooming
reports accordingly. • Describe general state of health (well, acutely ill or chronically ill)
• Level of comfort
– Comfortable or in distress
– Distress: speaks in phrases, tripod, orthopnea, squatting
• Level of consciousness
– Conscious, sedated, drowsy
Glasgow Coma Scale
Eye opening 4 Spontaneous
3 To voice
2 To pain
1 None
Verbal 5 Oriented
4 Confused
3 Inappropriate words
2 Incomprehensible words
1 None
Motor response 6 Obeys commands
5 Localizes pain
4 Withdraws
3 Abnormal flexion
2 Abnormal extension
1 None
• Ambulatory status
– Ambulatory – Wheelchair/Stretcher-borne
– Ambulatory with assistance – Bedridden
• Body habitus
– Hyposthenic/ectomorphic
– Sthenic/mesomorphic
– Hypersthenic/endomorphic
• Facies
– Moon facies
– Stare of hyperthyroid
• Mood and affect
– Towards examiner: cooperative, guarded, suspicious, evasive, hostile, seductive
– Predominant mood: neutral, anxious, fearful, elated, euphoric, angry, depressed,
– Affect: broad, restricted, labile; Intensity: blunted, flat, animated
– Appropriateness
2. Assesses patient’s orientation as to time, • Orientation: time, place, and person • Attention
place, and person; memory, • Memory: immediate, recent, remote • Calculation
3. Notes for any evidence of respiratory • Altered sensorium • Prominence of SCM
distress • Central cyanosis • Retractions
• Speaks in phrases • Abdominal paradox
• Tripod position
Preparation • Ask intake of caffeinated drinks, smoking, alcohol, illicit drugs, antihypertensive meds,
NSAIDs, and steroids. Note time amount of last intake.
• Instruct to avoid smoking. Intake of caffeine should be 30 minutes before taking of BP.
• Stay on the side of the extremity being measured.
4. Measures palpatory BP correctly. Reports • Use index and middle finger to palpate for radial artery.
findings. • Proper measurement of sphygmomanometer
– Width = 40% of upper arm circumference (12 to 14 cm)
– Length = 80% of upper arm circumference
• Apply cuff 2.5 cm above the antecubital fossa.
• Ensure the center of the inflatable bladder of the BP cuff is over the brachial artery.
• Wrap cuff snugly. Must be able to insert only 1 finger underneath the cuff.
• With one hand: palpate the radial artery pulse.
With other hand: inflate the cuff rapidly and note when pulse disappears.
• Reads BP on the manometer and states palpatory (systolic) BP.
• Deflate cuff.
• State that the same procedure will be done on the other side.
5. Measures auscultatory BP correctly. If Same preparation as above, except:
elevated, measures BP on other arm and • Use index and middle finger to palpate for brachial artery.
leg. (Leg BP may just be stated). Reports • With one hand, apply the bell of the stethoscope over the brachial artery.
findings. • Inflate the cuff rapidly 30 mmHg above the palpatory (systolic BP) previously
• Slowly deflate the cup by 2 to 3 mmHg/second.
• State the reading on the manometer when the first Korotkoff sound is heard as the
auscultatory systolic BP.
• Continue to deflate slowly by 2 to 3 mmHg/second and note level on the
manometer when Korotkoff sound disappears as the diastolic BP (phase 5).
• Classification of blood pressure:
Class Systolic Diastolic
Normal <120 <80
Prehypertension 120 – 139 80 – 89
Stage I Hypertension 140 – 159 90 – 99
Stage II Hypertension ≥ 160 ≥ 100
• State the same procedure will be done on the other side.
6. Assessment of orthostatic hypotension Compare BP and PR supine and upright. Orthostatic hypotension is present if there is:
• > 20 mmHg decrease in SBP
• > 10 mmHg decrease in DBP
• > 15 bpm increase in PR
7. Palpates for the patient’s radial pulse • Use index and middle fingers to palpate for radial artery pulse.
correctly. State the rate, rhythm, and • Count pulse rate for one full minute.
volume. • Note rhythm: regular or irregular. Note volume.
• State the same procedure will be done on the other side.
8. Determines respiratory rate in a subtle way. • Note number of rise/fall (cycles) of the vest for 1 full minute.
Describes and reports the rate and pattern – Normal: regular and comfortable at a rate of 12 to 20 per minute.
of breathing. – Bradypnea: < 12 breaths/minute vs. Tachypnea: > 20 breaths/minute
• Patterns:
– Sighing: frequently interspersed deeper breath
– Air trapping: increasing difficulty in getting breath out
– Cheyne-Stokes: varying periods of increasing depth interspersed with apnea
– Kussmaul: rapid, deep, labored
– Biot: irregularly interspersed periods of apnea in a disorganized sequence of
– Ataxic: significant disorganization with irregular and varying depths of respiration.
9. Takes the temperature and reports findings. Axillary temperature:
• Press the button.
• Place tip of thermometer underneath the axilla.
• Instruct patient to firmly keep the thermometer in place.
• Read and state the temperature indicated.
10. Measures BMI (height and weight will be BMI = Weight in kilograms/(Height in meters)2
provided) Underweight < 18.5 Obese I 30 – 34.9
Healthy 18.5 – 24.9 Obese II 35 – 39.9
Overweight 25 – 29.9 Obese III > 40

11. Inspects entire skin surface using penlight • Color: note presence of discoloration.
and ruler if necessary. States skin color • Note moisture, temperature, texture, turgor, and mobility.
texture, moisture, primary and secondary • Note primary lesions:
lesions. – Flat, nonpalpable: macule or patch
– Elevated, palpable: papule, plaque, nodule, or tumor
– Fluid filled: vesicle, bullae, pustule
• Note secondary lesions:
– Loss of skin surface: erosion, ulcer, fissure
– With material on skin surface: crust or scale
– Others: lichenification, keloid, scar, atrophy, excoriation, comedone,
• Describe lesions as to size, shape, location, configuration, color, blanching, texture,
elevation, depression, pediculation, presence of exudates, patter of distribution, or
12. Inspects and palpates the head and scalp • Note hair color, quantity, distribution, and texture.
systematically and reports findings. • Note presence of seborrhea or lesions.

13. Inspects for position and alignment of • Eyebrows – note symmetry, loss/extraordinary hair growth, presence of seborrhea
eyebrows, eyelids, eyes. Inspect for • Eyelids – note symmetry, matting or loss, crusting, redness, swelling
abnormalities of conjunctivae and sclera. • Eyes – note position, alignment, symmetry, size, shape
• Conjunctivae and Sclera
OD OS – Instruct patient to look up.
Lids Non-edematous Non-edematous
– Pull down lower lid of each eye to expose inferior sclera and conjunctiva.
Lashes Not matted Not matted
Conjunctiva Non-hyperemic Non-hyperemic – Using a penlight, inspect sclera and conjunctiva of upper eyeball for color,
Sclera Anicteric Anicteric vascularity, and swelling. Do the same for the other eye.
Cornea Clear Clear
AC Deep Deep
Iris Pigmented Pigmented
Pupil 2 – 3 mm RTL 2 – 3 mm RTL
Lens Clear Clear
14. Tests pupils for reactivity to light, both direct Direct and Consensual Test
and consensual as well as accommodation • Instruct patient to look into distance and not to focus on the light.
(CN II and III) • Illuminate both eyes with lest amount of light possible to discern pupil size and shape.
• Shine bright light in each pupil from a point slightly lateral to patient’s line of vision.
• Direct: check for pupillary constriction in eye that light is shined into.
• Consensual: check for pupillary constriction in eye opposite to one light is shined into.
• Instruct patient to look into distance and then at finger/test object held 2 to 4 inches
from bridge of patient’s nose.
• Check for pupillary constriction when focusing from distance to object held close.
15. Fundoscopy • Darken the room.
• Set the opthalmoscope at correct setting.
(+) ROR, OU; (-) Hemorrhages, spots, OU • Instruct patient to fix eyes on a specific point in distance and try not to move eyes.
AV ratio = 1:2; CD ratio = NV: 0.1 – 0.3 • Use opthalmoscope in right hand: looks through it with right eye to examine patient’s
(> 3 = Papilledema) right eye and later vice versa
• Shine beam into eye from a position approximately 12 inches from patient and about
15 degrees lateral to patient’s line of vision.
• Note orange glow in pupil, red reflex from retina, and opacities interrupting red reflex.
• Move closer to patient’s eye to examine, retina, optic disc, retinal vessels, peripheral
retina, and macular area.
• Describe disc margin, report cup/disk ratio, A:V ratio, absence or presence of
hemorrhages, exudates, cotton wool spots, copper wiring, AV nicking
• Repeat steps for the other eye.
16. Tests for visual acuity • Use Pocket Snellen or Jager – with and without correction
OD OS • Use Snellen chart - with and without correction, with pinhole
sc 20/20 J>12 sc 20/20 J>12
ph 20/20 J- ph 20/20 J-
cc 20/20 J>12 cc 20/20 J>12

17. Tests for central scotoma or distortion • Use Amsler Grid

18. Checks hearing acuity in each ear. • Ask patient to occlude each ear one at a time with his/her finger.
(Whisper test or watch ticking) • Use ticking watch, whispered or spoken voice to assess hearing acuity.
19. Assessment of hearing loss Rinne Test
• Place base of vibrating tuning fork against the patient’s mastoid bone and ask the
patient to tell you when the sound is no longer heard.
• Time this interval of bone conduction with your watch, note number of seconds.
• Quickly position the still vibrating tines 1 to 2 cm from the auditory canal and again
ask the patient to tell you when the sound is no longer heard.
• Time this interval of air conduction with your watch, note number of seconds
• Compare the number of seconds sound is heard by bone conduction versus air
conduction. Air conduction should be 2x as long as bone conduction.
Weber Test
• Place base of vibrating tuning fork on the midline of the patient’s head.
• Ask patient if sound is heard equally in both ears or is better in one ear (lateralization).
• Avoid giving patient a cue as to best response.
• Patient should hear sound equally in both ears.
• If lateralized, ask patient to identify which ear hears the sound better.
– Repeat procedure while occluding one ear.
Weber No Lateralization to Lateralization to better ear
lateralization affected ear
Rinne Air 2x longer Bone longer than air in Air longer than bone but
than bone affected ear less than 2:1 in affected ear

20. Inspect and palpate external ear for • Turn patient’s head to one side and downward to inspect auditory canal.
deformities, tenderness. • Grasp top of pinna, pull upward and backward to straighten canal.
21. Performs otoscopic exam properly and • Inspect for wax, discharge, foreign bodies, redness, and swelling.
report findings. • Inspect tympanic membrane for the following, note normal findings:
– Color: transluscent, pearly gray color
– Landmarks: umbo, handle of malleus, light reflex
– Contour: slightly conical with concavity at the umbo
– Perforations: none
• Inspect tympanic membrane for motion to assess Eustachian tube function.
• State the same procedure will be done for the other side.
22. Inspects nose structure, nostril patency, • Visually inspect and palpate nose for deformity, symmetry, inflammation.
septum position, inflammation of nasal • Elevate tip of nose with neck hyperextended.
mucosa. • Bilaterally inspect nasal mucosa.
• Inspect nasal septum.
23. Palpates for tenderness of the frontal, • Apply digital pressure with the thumb and index finger over the bony brow sides of
ethmoid, and maxillary sinuses. If tender, the nasal bone as well as cheekbone.
do trans-illumination.
24. Inspects lips, gums, teeth, tongue, floor of • Instruct patient to open mouth.
the mouth, and posterior pharynx. • With tongue blade and penlight visually inspect hard and soft palate, buccal
mucosa, gingiva, teeth, and tongue.
25. Examines palpable lymph nodes at • Using pads of index and middle fingers, move skin over underlying tissue in rotary
occipital, pre and post auricular, motion.
submandibular, submental, anterior or
posterior cervical and supraclavicular
areas. Reports findings.
26. With patient swallowing, palpates thyroid • Bimanually palpate thyroid by pushing gently to the right with the index and middle
tissue correctly for size, symmetry, and fingers of the left hand. This will allow palpation of the right lobe. Ask patient to
consistency. (May stand either in front of or swallow and assess.
behind the patient. • Repeat steps to examine the left lobe.
27. Assesses whether trachea is midline None
28. Describes configuration of the anterior • Normal: AP < lateral chest diameter (½:1)
chest. Note for deformities of the chest.
Compare AP to lateral chest diameter.
Identifies sternal angle of Louis and counts the None
spaces anteriorly.
29. Assesses symmetry of lung expansion Palpation:
(inspection and palpation). • Ask patient to cross arms over chest.
• Stand behind patient and place thumbs along the spinal processes at the level of
the tenth rib with palms slightly in contact with posterolateral surfaces.
• Watch thumbs diverge during quiet and deep breathing.
30. Palpates for any tenderness in the chest Tactile fremiti:
wall and performs tactile fremiti. • Ask patient to cross arms over chest.
• Ask patient to recite “Tres, tres”
• Systematically palpate chest with ulnar aspect of hands
31. Percusses anterior lung fields. • Percuss from apex to base of the lungs.
• Percuss both sides
• Diaphragmatic excursion:
– Prepare tape and measuring tape.
– Ask patient to take a deep breath and hold it.
– Percuss along the scapular line until you locate the lower border, the point marked
by a change in note from resonance to dullness.
– Mark the point with tape. Allow patient to breathe, and then repeat the
procedure on the other side.
– Ask the patient to take several breaths, to exhale as much as possible and then to
– Percuss up from the marked point and make a mark at the change from dullness
to resonance. Remind patient to start breathing. Repeat on the other side.
– Measure and record distance in centimeters.
– Normal = 3 to 5 or 6 cm
32. Auscultates anterior lung fields. • Use diaphragm of stethoscope.
• Note: vesicular, bronchovesicular, broncho-tracheal
33. Inspects back, cervical, and lumbar spine. Palpate each vertebral process from cervical to sacral.
Identifies inferior angle of the scapula and counts interspaces posteriorly.
34. Palpates for any tenderness in posterior chest wall.
35. Tests tactile fremiti, compares one side with another, tests top to bottom (patient’s arms crossed in front)
36. Performs percussion. Compares the percussion notes of both hemithoraces from top to bottom (patient’s arms crossed in front).
37. Inspects neck veins and identifies highest • Position patient properly
undulation of the right internal jugular vein – Lay patient supine in bed and raise patient’s head slightly on a pillow
and measures JVP at 30 or 45 degree – Raise head of the bed at about 30 to 45 degree angle
angle. – Turn the patient’s head slightly towards the left, exposing the right side of the neck
• Using a tangential white light over the right side of the patient’s neck, identify the

right internal vein pulsation.
• Identify the highest points of the right jugular venous pulsation.
• Measure the JVP.
– Identify the sternal angle of Louis by starting from suprasternal notch and slide
finger down until hump is felt.
– Place ruler graduated in centimeters vertically on top of the sternal angle of Louis
– Extend another ruler horizontally from the highest point of the jugular venous
pulsation perpendicular to ruler on sternal angle.
– Note vertical distance in centimeters above the angle of Louis at which the rulers
– State the JVP in centimeters.
38. Palpates for carotid artery pulse (one at a Note:
time) and describes. • Amplitude: 0 = absent, +1 = diminished, +2 = normal, +3 = full, increased, +4 =
• Contour: normal = smooth, rounded, domed
• Upstroke and downstroke
39. Auscultates for carotid artery bruit, one at a • Heard at just above the medial end of the clavicle and anterior margin of the
time. sternocleidomastoid muscle
40. Inspects precordium and reports its
dynamicity (adynamic, dynamic,
• At eye level, check for precordial bulging and visible pulsations on the precordium.
41. Palpates precordium and describes apex Palpation
beat (location, diameter, amplitude, • Palpate apex beat by using tips of the right index and middle fingers.
duration in relation to systole) • Location:
– While palpating the apex beat, palpate for sternal angle of Louis with other hand
– From sternal angle slide fingers laterally to the left intercostal spaces and count
what intercostal space the apex beat is located.
– Use a graduated (centimeter) ruler: note how far away from the left midclavicular
line and from the mid sternal line is the apex beat found.
• Diameter:
– Apply tips of the fingers directly on top of the apex beat and note the number of
fingers needed to cover the apex beat
• Amplitude:
– With fingertips, feel for the apex beat and note height of pulsation of the apex
beat whether normal or hyperdynamic
• Duration:
– While palpating the apex beat, auscultate for the first and second heart sound
and note duration of systole
– Note how much of systole does the apex beat occupy
– Normal: apex beat occupies only up to half of systole
42. Palpates for LV or RV heaves, LA or RA lifts, • Heaves:
abnormal pulsations over 2nd ISC RPSL, and – Using heel of the right hand palpate for abnormally strong pulsation (left
thrills. ventricular heave) or over the area of the apex beat
– Using the heel of the right hand palpate for abnormally strong pulsation (right
ventricular heave) over the left side of the lower sternum
• Lifts:
– Using fingertips, palpate for abnormal pulsation over the 2nd ICS RPSL for aortic
artery dilation
– Using fingertips, palpate for abnormal pulsation over the 3rd and 4th ICS LPSL for left
atrial lift
• Thrills:
– Using ball of the hand feel for fine vibratory sensations over the different clinical
valve areas
– Mitral valve: apex beat (5th ICS), LMCL
– Tricuspid valve: left lower sternum
– Pulmonic valve: 2nd ICS LPSL
– Aortic valve: 2nd ICS RPSL
43. Auscultates heart in following areas: mitral, • Apex: S1 > S2
tricuspid, pulmonic, aortic, auscultatory • Base: S2 > S1
valve areas using diaphragm in an inching • Carvallo Sign
manner and note character of S1 and S2 – Ask patient to inhale then auscultate at the tricuspid valve (left lower sternum),
and high pitch murmurs if any. note murmur
44. Shifts to bell and note for S3 and S4 and any
low pitch murmurs
Valsalva Maneuver • Ask patient to lie supine.
• Ask patient to forcibly exhale while occluding nostrils and closing mouth.
• Auscultate for:
– Systolic murmur of HCM (Hypertrophic cardiomyopathy; left side): becomes louder
– Systolic murmur of MVP (Mitral valve prolapse; left side): becomes longer and

• Unlike most murmurs which decrease in volume and duration, HCM and MVP
• After release of Valsalva maneuver, right-sided murmurs tend to return to control
intensity earlier than left-sided murmurs.
Instructs patient to relax, bend knees to relax • Stays at the right side of the patient
abdomen if needed and expose abdomen. • Drape patient appropriately – expose the abdomen from xiphoid process to
symphysis pubis.
45. Inspect abdomen: skin, contour, symmetry, • Skin: striae, scars, spider angioma, dilated veins
pulsations, visible peristalsis, umbilicus, • Contour: flat, scaphoid, protruberant, rounded
hernias (umbilical, inguinal) • Symmetry
• Visible pulsations
• Visible peristalsis
• Umbilicus: flat or everted
• Hernias: umbilical or inguinal
46. Auscultates abdomen: bowel sounds, bruit • Use diaphragm
if any (abdominal aorta, renal arteries, iliac • Bowel sounds: absent, hypoactive, hyperactive, borborygmi
arteries), and friction rub • Bruits
– Over epigastric area
– Costovertebral angles
– Liver
• Friction rub
47. Percusses abdomen systematically in all 4
• Note for areas of tympanism and dullness
48. Percusses for liver dullness (determine • Percuss lightly at the RUQ starting at a level below the umbilicus going upward
upper and lower border) and measures toward the liver and note for area of dullness = lower border
liver span along R midclavicular line • Percuss from lung resonance down toward the liver dullness = upper border
• Measure the vertical span of liver dullness at the MCL
• Normal liver span = 6 to 12 cm
49. Percusses for splenic dullness over Traube • From the sternal angle of Louis count down to the left 6th ICS
space in LAAL on deep inspiration. • Begin percussing at the LAAL down to the 10th ICS
• Note presence of splenic dullness
50. Systematically palpates the entire
• Warm hands before palpating.
abdomen first light then deep while looking
• Palpate with fingers together, flat on the abdominal surface
at the face of the patient. Note any direct
• Palpate abdomen initially with a light then with a deep but gentle dipping motion.
or rebound tenderness and any masses
• Palpate all quadrants.
and describe if present.
51. Palpates and describes liver edge. • Place right hand well below the lower border of the liver dullness
• Press hand gently in and up
• Ask patient to take a deep breath
• Feel the liver edge as it comes down to meet the palpating fingers
• Evaluate liver edge and surface: smooth, nodular, irregular, enlarged
52. Bimanual palpation of the spleen. • Ask patient to assume right lateral decubitus position
• Place left hand around and press forward the left lower rib cage
• Press right hand below the left costal margin toward the spleen
• Ask patient to take a deep breath
• Feel the tip or edge of the spleen as it comes down to meet the palpating fingertips
53. Bimanual palpation of the kidneys. • Stay at the side of the kidney being palpated
• Place ipsilateral hand and displace kidney anteriorly
• Place contralateral hand just below and parallel to the 12th rib
• Lift ipsilateral hand to displace kidney anteriorly
• Place contralateral hand gently at the right/left upper quadrant, lateral and parallel
to the rectus muscle
• Ask patient to take a deep breath
• At peak inspiration, press contralateral hand deeply into the right/left upper
quadrant just below the costal margin and capture kidney between two hands
• Palpate the kidney during expiration by slowly releasing the pressure of the
contralateral hand feeling for the kidney as it slides back into its expiratory position.
54. Checks for CVA tenderness. None
Murphy’s Sign • Place palpating fingers beneath the right costal arch just below the hepatic margin
• Ask the patient to take a deep breath
• While patient is inhaling, press fingers deeply beneath the arch
• Interruption of inhalation = positive Murphy’s sign = Cholecystitis (RUQ)
Obsturator test/Iliopsoas sign • Iliopsoas Sign
– Ask patient to lie supine
Interpretation: – Place hand over lower right thigh
Pain = Positive = Appendicitis – Ask patient to raise right leg, flexing at the hip, while examiner pushes downward
• Obturator Sign
– Ask patient to lie supine then flex the right leg at the hip and knee to 90 degrees

– Hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and
55. Shifting dullness and Fluid wave • Shifting Dullness
– After identifying borders between tympany and dullness have patient lie on one
side and again percuss for tympany and dullness and mark the border
– In patient without ascites borders will remain relatively constant
– With ascites, border of dullness shifts to the dependent side (approaches midline)
as the fluid resettles with gravity
• Fluid Wave
– With patient supine ask him/her to press the edge of the hand and forearm firmly
along vertical midline of the abdomen
– Place examiner’s hands on each side of the abdomen and strike one side sharply
with fingertips
– Feel for impulse of a fluid wave with fingertips of other hand
56. Rectal examination • Explain procedure to patient
• Ask patient to assume left lateral decubitus position with left leg stretched and right
knee flexed
• Drape patient appropriately
• Inspect perianal area for skin tag, lesions, external hemorrhoids, lumps, opening of
• Perform digital examination:
– Wear gloves on right hand and lubricate index finger
– Insert lubricated finger gently into the anal canal pointing toward the umbilicus
– Note for anal sphincteric tone
– Palpate anus on 4 quadrants and note for: mass, tenderness, internal hemorrhoids,
prostate size, consistency, tenderness, nodule, cervix, blood on examining finger
• Wipe perianal area after examination
Checks for mental status • Consciousness
(Can be done during the General Survey) – Conscious
– Lethargic: difficulty to maintain aroused state
– Obtunded: responsive to stimulation other than pain
– Stupor: Responsive to pain
– Coma: Unresponsive to pain
• GCS (see General Survey)
• Orientation
– Time
– Place
– Person
57. Checks for anosmia or parosmia (CN I) • Ask patient to close eyes
• Test each nostril separately, occluding the other side
• Present coffee, chocolate, or vanilla
Checks for visual acuity (CN II), fundoscopy • See HEENT
(Can be done during HEENT)
Checks conjugate extra ocular movements (CN • Ask patient to watch examiner’s finger as it moves through the six cardinal fields of
III, IV, VI) moving finger slowly to 6 cardinal fields gaze without moving his/her head or using his/her eyes only
of gaze.
(Can be done during HEENT)
58. Examines trigeminal nerve functions: None
sensation to face and muscles of
59. Checks muscles of facial expression • Raise eyebrows
(CN VII) • Squeeze eyes shut
• Wrinkle the forehead
Asymmetry of labial folds • Frown
Central Normal, symmetrical wrinkling of • Smile
facial palsy forehead, raising eyebrows, eye • Show teeth
• Purse lips to whistle
Bells palsy Complete paralysis of 1 side of face
• Puff out cheeks
60. Tests gag reflex and note elevation of None
palate (CN IX and X)
61. Can raise shoulder against resistance None
62. Asks patient to stick out tongue and note None
whether it is midline during protrusion

63. Checks motor strength of upper and lower • Test strength against resistance
extremities and compare L and R sides • Flexion/extension
including ROM • Abduction/adduction
• Internal/external rotation
0 No muscle contraction • State that the same procedure will be done on the other side
1 Flicker or trace of contraction • Dorsiflexion/Plantar flexion
2 Active movement with gravity eliminated • Inversion/Eversion
3 Active movement against gravity • Toe flexion/extension
Active movement against gravity and some
5 Normal movement

64. Checks sensory function of upper and None

lower extremities and compare L and R
65. Checks DTR • Biceps – C5, C6
• Brachioradialis – C6, C7
0 Absent • Triceps – C6, C7, C8
+ Hypoactive or + only with reinforcement • Knee – L2, L4
++ Readily elicited with normal response • Ankle – S1, S2
Brisk with/without evidence of spread to
neighboring roots
++++ Few beats of unsustained clonus
+++++ Sustained clonus

66. Checks for pathologic reflexes • Babinski reflex

67. Tests for motor coordination: finger to nose None
test (full arm extension) or alternate
pronation/supination test
68. Tests for balance/equilibrium: • Romberg Test
Romberg/Tandem gait test – Ask patient (with eyes open and then closed) to stand, feet together and arms at
the sides.
– Stand close, prepared to catch the patient if he/she starts to fall.
– Slightly swaying movement is expected but not to the extent that there is danger
of falling.
– Loss of balance = positive sign
• Tandem Gait Test
– Heal to toe walking
– Direct patient to touch the toe of one foot with the heel of the other foot
– Have the patient walk a straight line, first forward then backward with eyes open
and arms at the sides
– Consistent contact of the heel and toe should occur though slight swaying is
– Note any extension of the arms for balance, instability, tendency to fall, or lateral
staggering and reeling, shuffling, widely placed feet, toe walking, foot flow, leg
lag, scissoring, loss of arm swing
69. Checks for signs of Meningeal irritation • Nuchal rigidity
• Kernigs sign
– With patient supine, flex hip and knee to 90 degrees
– With hip immobile, extend the knee à resistance and pain
• Brudzinski sign
– With patient supine, flex neck à involuntary flexion of leg
70. Says thank you.