MED: PRACTICAL EXAMINATION

PHYSICAL EXAMINATION SHORT LIST

GENERAL SURVEY
Characteristic Look for
General appearance and skin color Well, acutely ill, chronically ill, Jaundice, cyanosis (central or peripheral), pallor
Facies Moon facies, hyperthyroid stare, Down’s, Marfan’s, Risus sardonicus
Comfort: level of speech (phrases) and position (tripod) – look for signs of cardiac or
Level of comfort, consciousness respiratory distress
Consciousness: GCS
Level of Consciousness GCS
Alertness 14 -15
Confusion – disoriented, impaired thinking
Lethargic – drowsy, opens eyes at loud voice 11 – 13
Obtundation – responds slowly confused after shaking
Stupor – arouse from sleep after painful stimuli 6-10
3 ( 4 -5 is semi-
Coma – no evident response
comatose)
Posture and gait, general motor Ambulatory status, relax, rigid, limping etc
activity Unilateral (pain/joint), symmetrical (proprioception/cerebellar) gait problems
If appropriate grooming, unkempt etc.
(unkempt in depression and dementia)
odor – characteristics ones like acetone for
Hygiene and odor DKA. Ammoniacal for kidney failure

Mood, affect, psychomotor activity Refer to Behmed module. ang dami eh haha.
and speech (Neutral, anxious, fearful, elated , euphoric, angry, depressed, irritable)
Behmed again - appropriateness, logical or not, relevant, rate of thought process (slow
Thought process and content
maybe hypothyroidism), presence of hallucinations etc
Cognitive functions Refer to neuro exam! Memory – remote, recent, and immediate memory
METHODS OF PE
Possible next PE
Remember Possible Diseases
maneuvers
Hyperthyroid – jittery and fast
movements
Inspection Begins with first exposure, General survey Hypothyroid – cold intolerance and HENT neck exam
hoarse voice
Pulmonary problem - Retractions
Light palpation, deep palpation, bimanual Distal MCP – thrills, AV fistula, artery bruit
Palpation technique Proximal MCP – heaves, heart enlargement, precordial heave
Rebound tenderness – peritoneal irritation Ulnar MCP – vocal vibrations, pleura and lung

Percussion

Performed last except in GI exam (palpation is last)

Auscultation
Diaphragm first then bel

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)

 SKIN
Number Solitary, few, multiple 4 Cardinal Factors Describing Lesions
Confluent, grouped, bilateral Refer to summary of morphologic
Distribution Type
symmetrical, generalized lesions
Shape/ Configuration

Erythematous skin colored,

hyper/hypopigmented,
Color
depigmented,
grayish, purpuric

Arrangement
Border Well- or ill-defined, annular,
/Shape/ nummular, with central
Symmetric, Asymmetric, Discrete, Lines
Configuration clearing, targetoid
of cleavage

Primary Macule, papule, patch,

Lesion plaque, pustules, vesicles
Secondary Scale, crust, lichenification,
Lesion excoriations
Distribution
Areas of Face, cheeks, axilla,
involvement buttocks
Flexural regions – atopic eczema
Sun-exposed regions – CT disorders
Acrodermatitis – zinc deficiency
Clothing covered regions – contact
If multiple, give the range dermatitis, heat rash
Measurement Acneiform
(smallest to largest)

Summary of Morphologic Lesions

Other Lesions

Nails

Hair
Alopecia Areata, totalis, universalis, ringworm, scarring
Trichotillomania Physical random plucking out the hair
Telogen efflevium patient’s scalp and hair distribution appear normal, but the positive hair pull test reveals most hairs
have telogen bulbs

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)

 EYE EXAMINATION
Visual Acuity
Test Procedure Remember
14 inches away, px read the sentence
One eye at a time, start with bad eye. Check for
Near-vision (Jaeger)
Start without corrective glass then with improvement after wearing corrective glasses.
corrective glass.
Initially 20 feet away One eye at a time
10 feet → 8 feet → 6 feet → Counting Lowest line where majority of letters read accurately
fingers (cannot read 5/200) → Hand
Far-vision (Snellen)
movements → Light perception Numerator – testing distance
Denominator – distance at which a person with normal
(20, 10, 2, CF, HM, LP) eyesight can read the letters
Patient’s vision IMPROVES: refractive errors
Refractive Error (Pinhole)
Patient’s vision WORSENS: with central problems
Screening: both eyes
Fully extend arm then slowly bring arm Further testing: One eye at a time, keep 1 meter/2 feet
Peripheral Visual Acuity centrally. Ask to point to finger once seen. distance from patient.
(Confrontation Testing) 4 quadrants: (nasal superior, nasal inferior,
temporal superior, temporal inferior) Measure normality in comparison to own peripheral
visual acuity.
External Examination
Part Note
Hair abnormalities, seborrhea, eyelash matting, symmetry, swelling of eyelids. (Abn: alopecia areata,
Eyebrows, eyelids, eyelash
madarosis, dacrocystitits, proptosis – bird’s eye view)
Check both superior and inferior sclera using penlight.
Bulbar conjunctiva: check for icteric sclera
Sclera, Conjunctiva
Palpebral conjunctiva: check for pallor in anemia.
Normal: white sclera, pink palpebral conjunctiva
Orbits Position, alignment, symmetry shape. Height of cornea in relation to brow to examine asymmetry.
Cornea: oblique and direct light.
Cornea, pupil, and iris Pupil: note for opacities
Iris: size, shape, markings, color.
Extraocular movement, Motility and Alignment (Strabismus)
Extraocular movement Follow index finger with eyes only, trace letter H path for 6 cardinal positions of gaze.
Shining penlight shows equal light reflection by both eyes. Decentration of corneal light reflex is
Hirschberg test
measured at 18 pd/mm, check for misalignment or inward deviation
Cover Uncover test – Uncovering unmasks deviation.
Strabismus test Inward movement of eye upon removal of cover – exotropia (Divergent misalignment)
Outward movement of eye upon removal of cover – esotropia (Convergent misalignment)
Pupillary Testing
Afferent: Optic N. Efferent: Oculomotor N.
Pupils constrict when light is
Pupillary Reflex Direct reflex is strongest
shone
Consensual reflex is usually weaker
Afferent: Optic N. Efferent: Oculomotor N.
Compare direct and consensual reflex. (When swung to opposite pupil,
Swinging Light Test
Marcus Gunn pupil/ RAPD: Consensual reflex is intact (okay CN3) it should constrict more)
but direct reflex shows only dilatation (CN2 problem)
Indx finger at 2 feet moving toward to px nose CN III constricts pupils as eyes
Accommodation/
Accommodation: CN3 focus on a near object (near
Convergence
Convergence: CN3,4,6 reaction).
Ophthalmoscopic Examination
Points to Remember Parameter Findings
(+) ROR, no opacities blocking the
Use R hand in examining Orange glow and ROR
ROR
px right eye.
Sharp disc margins
L hand – L eye. Disc margin
Blurred – papilledema (high ICP)
Dark room, angle of 15 –
0.3 – 0.5
20 deg lateral to line of
Cup:Disc ratio Cup is slightly depressed and lighter
vision.
than disc
2:3 or 4:5 – Veins are darker and
Diopter disc: A:V ratio
arger
Convex lenses –
counterclockwise No exudates, cotton wool spots,
Concave lenses - microaneurysms, microvascular
Other findings:
clockwise abnormalities, neovascularization or
vitreous hemorrhage

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)

 HENT
HEAD
Inspection Same level or slightly higher than px.
Palpation Rotatory movement from frontal towards occipital area.
Auscultation Vascular anomaly detected over temporal region/over eyes /below occiput by using bell
EAR
Top of ear reaching line drawn from outer canthus
of eye to occiput
Inspection, Palpation Tragus tenderness – external auditory canal problem
Tenderness of the auricle, mastoid process, tragus
(tragus inward toward ear canal)
Unaffected ear first, tip head towards opposite Functional eustachian tube – pars flaccida movement
shoulder, largest speculum, pull auricle upward Intact tympanic membrane, not bulging, with white reflex light
and backward (cone of light)
Tympanic membrane – cone of light reflex identify
parts
Otoscopy
*Valsalva (blow) and Toynbee (swallow) maneuver
– eustachian tube function

Integrity of Outer cartilaginous (1/3) + Inner bony

(2/3)
Voice/Whisper Test Behind at 2 feet distance Abnormal if 50% or more whispered items are incorrect
Stopwatch/Tick Test Whisper – 30 dB
Finger rubbing test 40 dB – finger rubbing test on inch away from Px
512 Hz tuning fork on middle of
Weber Test forehead or top of head midline.
Lateralization
512 Hz tuning fork on patient
mastoid process then EAM.
Rinne Test
Compare duration of bone
conduction and air conduction
Compare bone conduction of
Swabach’s Test
examiner with that of patient
NOSE
Inspection and deformity, symmetry, inflammation, or alar flaring
Palpation Patency of each nostril, septal deviation, perforation. Inspect upto middle turbinate if using penlight.
See inferior turbinate, floor of the nose, Liitle/s Nasal fracture - crepitation
Endoscope area/Kisselbach’s plexus, middle turbinate, meatus,
pharynx, eustachian tube
SINUSES
Frontal and maxillary sinus – thumb and index finger Absence of glow suggests sinus is filled with fluid
Palpation
Palpate or percuss to detect tenderness
Transillumination Check for degree of congestion Also examine sphenoid and ethmoid
MOUTH / OROPHARNX
Inspection and Palpation TMJ tenderness, crepitus, or locking. Inspect for malocclusion. Inspect salivary glands
Check Stensen’s duct – opposite second upper molar
Cheek and Oral Mucosa
Retromolar trigone – asymptomatic carcinoma
Tongue, Soft palate (CN 10 and Anterior 2/3 - Lingual nerve – sensation, Facial (chorda tympani) taste
12) Posterior 1/3 – CN 9 – sensation, and taste
Oropharynx, Post. Tongue, Uvula Gag reflex – posterior wall of the pharynx
(CN 9)
Lateral and Ventral Tongue Examine with depressor
NECK
Normal relaxed – deviation or bulge by looking from the side. Thyroglossal duct cyst – neck mass in the midline
Neck in slight extension – thyroid isthmus below cricoid of the upper half of the neck that slides upward
Thyroid Gland –
cartilage – swallow and note for mass or bulge on lobes. when the tongue protruded
Anterior
Displace thyroid gland – use same side thumb and palpate Brachial cleft cyst – anterior portion of the SCM
with opposite side thumb and index anywhere along its course
Neck slightly flexed – turn head side to side Goiter – greater the 20 mL
Thyroid Gland –
Grade 1: palpable but not visible
Posterior
Grade 2: palpable and visible
Thyroid Gland – Using bell of steth, auscultate for bruit (hyperthyroid increase
Auscultation vascularity and blood flow)
Simultaneous left and right index and middle finger in order:
1. Preauricular Pre, Post, Occ, Ton, max, ment, cerv, clav
2. Post auricular Pare, post oct-to-ber, max na mental health cos of
3. Occipital , suboocipital Covid (C for cervical and clavicular) HASJDHAS
Lymphatics 4. Tonsillar IDK
5. Submaxillary
6. Submental
7. Superficial cervical over SCM
8. Supraclavicular
Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)
 VITAL SIGNS
NOTE

TEMPERATURE

Typmpanic Membrane: Closest to core temperature, higher than oral by 0.8

Radial Pulse
- Locate radial artery using index and middle finger.
PULSE
- Count Pulse in full minutes Normal: 2+ and 3+
- simultaneously palpate radial pulse of both arms. Normal PR: 60-100 bpm
Determined in a subtle way by pretending to continue
RESPIRATORY
counting pulse rate and note the number of rise/fall Normal RR: 12-20 breaths/ min
RATE
(cycles) of the chest for 1 full minute and pattern
Vefiry (30-60 mins before BP): caffeinated drinks, alcohol, illicit drugs, antihypertensive meds, NSAIDs and steroids,
smoking cigarettes, exercise or its equivalent

Rest for 5 minutes

PALPATORY BLOOD PRESSURE AUSCULTATORY BLOOD PRESSURE.
- To provide preliminary approximation of SBP and - . Maintain the midpoint of the upper arm (brachial artery
Ensures adequate level of inflation for the actual level) always at the level of the hear
auscultatory measurement and/or avoid overinflation • Below heart = BP will be Higher
• Above Heart = BP will be Lower
Measurement:
1. Inflate with increment of 10mmHg until the pulse CUFF: encircle 80% of upper arm, inflattable:40%, 1 finger
disaapperar under the cuff
2. Confirm by increasing 20-30 mmHg • Too narrow = BP will be High
3. Deflate the cuff by 2-3 mmHg/sec • Too tight = BP will be Low
4. Wait for 15-30 seconds before taking the
BLOD Auscultatory BP Measurement
PRESSURE 1. Inflate until 20-30 mmHg above the palpatory BP
2. Deflate by 2-3 mmHg/sec
3. Auscultation
✓ 1st Korotkoff (Phase I): Systolic BP
✓ Muffle Korotkoff (Phase IV)
✓ Disapperance of Korotkoff (Phase V): DSP
4. Record the Korotkoff Phases I/IV-V (e.g. 140/70-30).
*Palpated SBP is about 7 mmHg (5 – 10 mmHg) lower
than the auscultatory value

*Memorize Classification of Blood Pressure

Orthostatic Hypotension = Hypotension within 3 TEST:

minutes after quick standing 1. Read BP after 2 minutes of assuming supine position.
DETECTING Examiner 2: takes PR
ORTOSTATIC • > 20 mmHg drop in SBP and/or 2. Stand atleast 3 minutes after taking supine BP
HYPOTENSION • > 10 mmHg drop in DSP 3. Read Standing BP and PR.
• > 30/min increase in PR + dizziness

ANTHROPROMETRIC MEASUREMENTS
NOTE

BMI

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)

 NEUROLOGICAL
CEREBRUM
LEVEL OF *Refer to General Survey
CONCIOUSNESS
Includes Assessment of Attention, Memory, Orientation, Perception, Though Process & Content, Insight,
Judgement, Affect, Mood Language, and Executive Functions
MENTAL STATUS
***Check MMSE
CEREBRUM
MOTOR COORDINATION EXAM
Rapid Alternating Pronation/ Supination
Finger to Nose Test Heel-Knee-Shin Test
Test
Place on heel on the opposite knee and
Follow examiner’s index finger and then his/her Both hands on the lap. Quickly and repeatedly
run it own down the shin. Repeat on
nose pronate and supinate hands at the same time
opposite leg.
Take note of the smoothness & accuracy of the Observe this movement for smoothness
movement and accuracy
Tremors, Dyssynergia, Dysmetria Dysdiadochokinesia
TEST FOR BALANCE & EQUILIBRIUM
Observed as soon as the patient enters the room. Ask the patient to copy.
Ask the patient to walk around the room and - Heel-to-toe
GAIT observe the following: - Tip toe
1. Posture/ Stance - Hop in place
2. Stability
TANDEM GAIT Walking in one line, Heel-to-Toe. Note any Truncal/Gait Ataxia.
Closed Eyes, and Stand with Closed Feet.
Test also for Vestibular portion of CNVIII
ROMBERG’S TEST
*Examiner should place his/her arm in front of the (+) Swaying/ Falling = ATAXIA
patient, in case the patient falls
POSITION SENSE
Test for patient’s orientation
Closed Eyes and Arms Forward
(-) arm drifting: normal (+) arm drifting
CRANIAL NERVES
*Avoid noxious substances (ammonia and vinegar):
Closed Eyes and smell different odors. One
CN I: OLFACTORY stimulates CN V (Trigeminal)
nostril at a time
*Not routinely done.
CN II: OPTIC, CN III: OCULOMOTOR, CN IV: TROCHLEAR, CN VI: ABDUCEN: ***Check Eye PE
SENSORY MOTOR
Closed eyes. Brush cotton and lightly prick Clench teeth. Palpate the masseter and temporal muscles
Forehead, Cheeks, and Jaw on both sides of for firmness on both sides;
the face.
CN V: TRIGEMINAL there SHOULD BE NO JAW DEVIATION
Ask the patient to Identify, discriminate, and
locate the stimulus.
CORNEAL REFLEX:
Look at a distant object and not blink. Light touch cornea with cotton. (+) Forceful Blink
SENSORY MOTOR
Closed Eyes. Protrude Tongue. Voluntary Facial Movement (Frowning, Smiling, Winking
CN VII: FACIAL NERVE
Apply Salt and Sugar on Ant. 2/3 of the Tongue etc)
Ask the patient to discriminate the tast Note for Asymmetry and Paralysis.
CN VIII: VESTIBULOCOCCHLEAR, CN IX: GLOSSOPHARYGEAL. CN X: VAGUS *Check HEENT
CN XI: SPINAL Shoulder shrug and Neck Turning. Apply Resistance.
ACCESSORY Note for asymmetry and palpate for tone.
CN XII: HYPOGLOSSAL Check for deviation of the tongue. Deviated to weaker muscle.
MOTOR
1. Position of the body during movement
Assess MUSCLE TONE by feeling for muscle resistance
OBSERVE 2. Involuntary Movement
to passive stretch
3. Muscle Bulk
MUSCLE STRENGTH – MANUAL MUSCLE TESTING (MMT)
Closed Eyes. Stand in Closed Feet. Arm
UPPER EXT. DRIFT Forward for 15-30 seconds
Observe for slow drop/Pronation = (+) UMN def.
Grasp the Index and Middle fingers of the
Examiner
HAND GRASP
Examiner will try to pull his finger from the grip
Assess the tightness of the grip
Prone position. Flex knees and leg pointing
LOWER EXT DRIFT upward for 15-30 secs
Observe for slow drop = (+) LMN Defect
TOE & FOOT
Try to dorsiflex while resistance is applied
DORSIFLEXION

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)

 SENSORY FUNCTION TESTS
Pain and temperature: Spinothalamic tract
GENERAL Position and Vibration: Posterior columns
Light touch: Both pathways (spinothalamic and posterior columns)
Closed Eyes
LIGHT TOUCH SENSATION Apply stimulus (cotton/examiner fingertip).
Ask the patient to identify the presence of stimulus
Closed Eyes
Check both sides
SUPERFICIAL PAIN Lightly apply alternately needle point (sharp) and
Start the exam from the
SENSATION hub (dull) on the skin
1. dorsum of the hand,
Ask to identify if sharp or dull.
2. ventral surface of the forearm,
Closed Eyes
3. expose the abdomen to test the four quadrants,
Alternately apply test tubes with warm and cold
TEMPERATURE 4. to the toes going to the dorsum of the foot,
water
5. to the shin of the lower leg
Ask the patient to identify if cold or warm.
Closed Eyes.
TWO POINT
Perss 1-2 needles on the skin
DISCRIMINATION
Ask how many were felt.
COMATOSE: gradual pressure on patient’s thumb nail
bed/ big to nailbed
Squeeze hard Bicep Tendons using index finger
DEEP PAIN SENSATION
and thumb
Note for any facial grimace, decorticate, or decrebrate
posturing = Intact Sensory Pathway
Closed Eyes
Strike tuning for and apply the base to one of patient’s bony prominence (clavicles, sternum, finger joints,
VIBRATION SENSE
wrists, ankles)
Patient to tell “Yes “ if vibration is sensed. “None” if it stopped.
Orient the patient what is uo and down If the patient cannot identify, use a more proximal joint.
Closed Eyes. Grasp the most distal joint (fingers or
JOINT POSTION SENSE
toe) then move it up or down
Ask the patient to identify the movement
Place a familiar object on the patient’s hand and Reflects integrative function of the parietal & occipital
ask the patient to identify it by touch alone lobes
(stereognosis) Normal: Identify >90% in 5 secs
Touch one finger of the patient and ask the latter
SENSORY ASSOCIATION
to identify which finger is being touched and which
side (topognosia)
Trace a letter or number on the patient’s palm and Normal: 1 cm in height on fingertip & 6 cm
ask to identify it (graphognosia) elsewhere

REFLEXES
NERVE
REFLEX HIT RESPONSE
ROOTS
C5, C6 Biceps Tendon
Biceps @ antecubital Forearm flexes at the elbow
fossa
C5, C6 Styloid process Flexion and supination of
Brachioradialis
of the radius forearm
C6, C7 Triceps tendon
Triceps Reflex @ olecranon Extension of the elbow
fossa
L2, L4 Leg Extension
Patellar/ *Jendrassik maneuver: lock
Patellar Tendon
Quadriceps fingers & pull them apart for 10
secs = enhances reflex
Achilles S1, S2 Achilles Tendon Plantar Flexion
PRIMITIVE REFLEXES
Test for UMN Lesion. (+) Babinski sign: fanning of toes and
BABINSKI
stroke the lateral aspect of the sole from the heel to the ball of the foot dorsiflexion
CHADOCK’s Scratching below lateral malleolus
OPPENHEIM Rub anterior shin (+) dorsiflexion of big toe
GORDON Squeezing of calf muscles

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)

 MUSCULOSKELETAL
ARTHRITIS
Is it Articular Is it acute or chronic
ACUTE CHRONICS
✓ Trauma ✓ Osteoarthritis
✓ Infectio ✓ Osteonecrosis
✓ Crystal-induced Arthritis ✓ Charcot Arthritis
✓ Reactive Arthritis ✓ Chronic Inflammatory
✓ Initial presentation of Arthritis
systemic arthritis

Is it Inflammatory How many Joints are involved

DISC HERNIATION
Supine - examiner raises patient’s extended leg with ankle
dorsiflexed
(+) when sciatica is reproduced between 10 & 60 degrees of hip
flexion

RANGE OF MOTION
Stationary Arm Moving Arm Fulcrum Normal
Neck flexion and pointed at the tip of the
shoulder 60
extension nose
Lateral neck rotation Spinal area C7 area 45
Lateral bending Spinal area C7 area 45
Shoulder Flexion Ask the patient to bend their elbow and flex the shoulder 180
Internal and external
Place patient in supine with hands apart 90
rotation of the shoulder
Elbow Flexion and both sides are of the
Varies between 150° - 0° depending on muscle size
extension same degree
Forearm Measure pronation and supination
Wrist flexion and
Flexion: 0-80°, Extension: around 70° (has smaller angle)
extension
Radial and ulnar
Radial deviation: 20°, Ulnar Deviation: 30°
deviation
DE QUERVAIN’S TENOSYNOVITIS
put thumb in palm, wrap four fingers around it, elbow 90 degrees, do
Finkelstein’s test (+) Finkelstein = PAIN
ulnar deviation
(+) Tingling sensation = Median Nerve
Tinel’s Sign Percuss over the volar surface of the wris
Compression
Phalen Sign wrist in palmar flexed position for 1-2 minutes (+) aggravated wrist burning sensation

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)

Renz Dwine Mendoza | Mileena Nichole Morales (Nov2020)
 CARDIOVASCULAR PE – SHORTLIST

LOCATIONS, WIGGER’S PHASES

Left atrium Left parasternal area

Mitral Valve 5th LICS MCL S2 softer
Tricuspid Lower left (2/3/4th ICS)
Split S1 with deep breath
Valve Parasternal
Pulmonic Louder S2, split with
2nd LICS Parasternal
Valve inspiration
Aortic Valve 2nd RICS Parasternal
Aortic and pulmonic origin
Erb’s point 3rd/4th LICS PS
sounds

P wave Atrial depolarization

PR segment AV node to Bundle branch depolarization
QRS complex Ventricular depolarization
T wave Ventricular repolarization
PQRST
Precedes mechanical activity
complex
Ventricular Atrial Aortic
Pressure / Volume Pressure Pressure
Atrial Systole EDV A wave
Isovol. Contraction C wave Minimum
Rapid Ejection Inc. pressure
Slow Ejection

Isovol. Relaxation V wave

Rapid Filling
Slow Filling
INSPECTION

Adynamic precordium No visually seen movements

Dynamic Precordium Noticeable movements, 1 visible pulsation
Hyperdynamic precordium More prominent movements, 2 or more visible pulsation

PALPATION

RVH, LVH ARTERIAL PULSES

Enlarged chamber or vessel.
Heaves Heel of hand
LV heave – apical, RV heave – Left lower
parasternal Evaluate rate of rise, contour, pulse
Pulmonary artery, aorta, atrium volume while always comparing
LA lift – 3 or 4th LICS PS both sides. Use middle and index
Lifts Heel of hand finger
PA lift – 2 LICS PS
Aortic Lift – 2 RICS PS
Palmar pads of fingers Aortic coarctation, aortic dissection,
Thrills Ball of hand Valve areas Radial – Femoral Pulse delay
subclavian artery stenosis
Assoc with at LEAST grade 4/6 murmur Raising arm above head will cause
Localized tapping impulse through muscle
Apex beat Fingertips Collapsing pulse (water hammer
pulsations bulk of arm. High output physiologic
pulse)
states of fever and pregnancy, aortic
regurgitation, PDA

POINT OF MAXIMAL IMPULSE / APEX BEAT

NORMAL PATHOLOGIC
LOCATION 5th LICS MCL 6TH LICS – LV DILATED
3/4/5 LICS – RV Hyperkinetic or pressure overload
Left sternal border to subxiphoid – RV volume overload.
LATERAL DISPLACEMENT – volume overload, DILATATION
DIAMETER 1 ICS (<2.0 cm), 1 ½ fingertips wide DIFFUSE = Volume overload / HYPERTROPHY (Enlargement in general)
DURATION Stops before / 2/3 of systole SUSTAINED (After S2) - HYPERTROPHY
AMPLITUDE Small, feels like gentle tap, single upper deflection Double impulse = LVH or cardiomyopathy resulting to decreased ventricular
compliance
Use fingertips, coincides with S1 or immediately after LV heave + sustained diffuse PMI → LVH
Accentuate – LLD, exhale fully and pause breathing
 CAP

Ventricular contraction, follows S1,

Rapid upstroke
precedes S2
Dicrotic notch / incisura Aortic valve closure
Downstroke Less abrupt than upstroke
Amplitude Cardiogenic shock – small, thready
Aortic regurgitation - bounding
VARIOUS WAVEFORMS

Pulsus parvus et tardus Delayed upstroke, aortic stenosis

2nd peak ejects blood in the aorta the

Pulsus bisferiens flows back to LV,
Aortic regurgitation, HOCM

Shortened first waveform as

compensatory pause for PVC. Every other
Pulsus bigeminus
beat is a premature ventricular
contraction

2 peaks of both systole and diastole,

Dicrotic pulse
fever, amyl nitrite

Amplitudes alternately high and low,

Pulsus alternans heart cannot pump consistently strong,
sever depression of myocardial function
Auscultate prior to palpation for bruit to avoid dislodging a carotid plaque.
Bony landmark – thyroid cartilage -> cricoid -> lateral
Procedure
Never palpate both sides at same time
Palpating above thyroid cartilage -? Slowing heart rate

JVP

Tricuspid
Phase Heart Sounds CAP Abnormalities
Valve
Prominent in tricuspid
Atrial Before Carotid stenosis, pulmo hpn
A Open Before S1
contraction upstroke pulmo stenosis, SVT
Absent in A. Fib
S1
Ventricular
C Open After S1
contraction
Atrial
X Closed systole
relaxation
Large in Tricuspid
Large in high volume
Regurgitation.
Atrial venous states or Tricuspid Apex of carotid
V Closed Constrictive
filling regurgitation pulse
pericarditis, atrial
Before S2
septal defect
S2
Ventricular Immediately after
Y Open After S2
filling carotid pulse
Vertical distance between sternal angle and top of pulsation of IJV
Normal
4.5 cm at 45 deg. Or 3cm at 30 deg
 HEART SOUNDS

S1234

S1 S2 S3 S4
Tri/bicuspid valve closure Pulmonic/Aortic Valve Closure Rapid filling Atrial gallop, presystolic gallop
Louder at Apex Louder at Base Best at apex with bell LLD Best at apex with bell LLD
• Physiological S3 → Due to
• Loud S1 → Mitral stenosis → • Persistent/Widened Splitting → increased velocity of ventricular Rarely physiological
Hyperdynamic state → Pre- Pulmonic Stenosis → Complete expansion ▪ Tachycardia ▪ ● Commonly pathological →
excitation → Short cycle length AF Right Bundle Branch Block → Nervousness Decreased distensibility or
• Soft S1 → Mitral regurgitation → Mitral Regurgitation. • Pathological S3 → Due to loss of compliance of the LV
Aortic regurgitation → Myocardial • Fixed Splitting → Atrial Septal compliance or distensibility of the ● Best heard with the bell at the apex
Infarction → Shock → Myxedema Defect → RV Failure ventricle → Heart failure with the patient on left lateral
→ Left Bundle Branch Block • Paradoxical Breathing → Left • CONGESTIVE HEART FAILURE Decubitus
• Varying Intensity of S1 → Complete Bundle Branch Block → In • MR, VS, PDA
● LVH, CAD Hypertension
heart block → Wenckebach paradoxical splitting, the pulmonic ● Right sided S4 – pulmonic stenosis /
● Right sided S3 – pulmonic
phenomenon → Atrial fibrillation valve closes first → Aortic valve HPN
regurgitation/ severe TR
→ Pulsus alternans → Massive takes a long time to close.
pericardial effusion • Accentuated P2 – Pulmonary
• Split S1 → S4 that precedes S1 hypertension

S1 → S2: Systole S2 → S1 Diastole After S2 Before S1

MURMURS

Pathologic Murmurs
Differentials Physical Exams
23RICS midsystole / Holosystolic crescendo-decrescendo murmur, RADIATING TO THE CAROTIDS/NECK
Delayed carotid upstroke.
Sustained apical impulse.
Aortic Stenosis Small weak pulses
LV pressure overload: Sustained LV impulse
A2 intensity decreased? If calcific
PMI >2.5 cm if LVH dt stenosis or HPN
2-4 LICS early diastolic decrescendo murmur
Austin Flint murmur – severe AR: low pitch mid-diastolic murmur at mitral area (AR preventing MV from closing)
Widened pulse pressure.
Aortic
Diffuse apical impulse, displaced laterally and downward.
Regurgitation
Bisfiriens pulse, Bounding carotid pulse.
LV volume overload: Displaced diffuse LV impulse
Hyperkinetic high-amplitude impulse
23 LICS Mid-late systolic crescendo-decrescendo (diamond) murmur, RADIATE TO LEFT SHOULDER and neck.
Normal JVP, prominent a wave – maybe
Pulmonic Stenosis
Pulmonic ejection sound
RV pressure overload: Sustained RV impulse
Pulmonic
Early diastolic decrescendo murmur
Regurgitation
Apex pansystolic blowing murmur, not changing with inspiration. RADIATES TO AXILLA
Mitral Apical S3, apical impulse diffuse and laterally displaced
Regurgitation Sustained parasternal impulse from dilated left atrium.
LV volume overload: Displaced diffuse LV impulse
Apex: Opening snap diastolic murmur with pre-systolic accentuation
Rumbling/plateau configuration
Mitral Stenosis
Ps accentuated if w pulmonary hypertension.
Palpable RV impulse and more prominent a wave of JVP.
Lower left sternal border holosystolic blowing murmur, increases with inspiration (Carvallo sign). S3 at left sternal
Tricuspid border
Regurgitation JVP OFTEN ELEVATED (v wave elevated)
Pulsatile liver, ascites, edema
Mid to Late diastolic rumbling murmur at apex
Tricuspid Stenosis
Left PSL to Right PSL
Patent Ductus Continuous murmur in systole and diastole, silent interval late in diastole.2 LICS, radiates toward left clavicle.
Arteriosus MACHINERY LIKE
Holosystolic murmur at 345 LICS
VSD
May cause L→R shunts pulmonary hypertension, RV overload
Pericardial Friction
Coarse grating sound with one two or three components. Rubs are heard with or without pericardial effusions 3 LICS PS.
Rub
Holosystolic murmur, not radiate to the neck, inc intensity when standing.
Hypertrophic Like aortic stenosis
Cardiomyopathy Rapid carotid upstroke
Sustained apical impulse, S4 at apex
 PHYSIOLOGIC MURMURS PATHOLOGIC MURMURS
Never passes mid-systole, May be in any phase, louder,
usually at the base with thrills (4/6 grade)
Crescendo - Decrescendo

SYSTOLIC MURMURS DIASTOLIC MURMURS

Immediately after or with CAP Before CAP
S1 → S2 S2 → S1
Before S2 After S2

DYNAMIC AUSCULTATION

Increases all R sided murmurs except pulmonic

Inspiration
RESPIRATION ejection (Carvallo’s sign)
Expiration Increased L sided murmurs
LLD Increase mitral / tricuspid murmurs
Sit Up, Lean Forward Aortic / pulmonic murmurs
POSITION
Squatting Shorter MVP murmur
Standing Longer MVP murmur
Only MVP increases in intensity and duration.
Valsalva (Strain phase)
HOCM murmur also increases
Valsalva (Release phase) Inc. intensity aortic stenosis
Isometric handgrip Inc. MR, MS, AR, PS, VSD
MANEUVERS
Transient Arterial Occlusion Dec. MR, AR, VSD
Widened S2 split (both inspi and expi)
Leg Raising Inc. systolic murmurs
Shorter MVP and HOCM murmurs
 RADIOLOGIC IMAGING

PA view Lateral view

Clavicle over lung fields Clavicle above lung apex
SVC/IVC Right side of mediastinum
Right Atrium Right border
RVH obliterated retrosternal
Right Inferior border, can extend
space, should occupy only
Ventricle forward
2/3
Pulmonary
Hilum of silhouette
Artery
Left atrium
Posterior border, may
Left border, can extend
Left ventricle obliterate prevertebral space
backward
Descending aorta anterior to
Aorta Knob above hilum
spine

ECHOCARDIOGRAPH, ECG
 GASTRO INTESTINAL PE – SHORTLIST

MAPPING THE ABDOMEN

Simplest but Vague

3 AREA MAPPING

Liver, gallbladder, upper part of the duodenum, hepatic flexure of

Epigastric colon, splenic flexure of the colon, upper pole of the right and left
kidney, suprarenal gland, stomach, spleen, pancreas, aorta
Periumbilical Omentum, mesentery, lower part of the duodenum, jejunum and
ileum, ascending colon, transverse colon, lower half of the right
and left kidney
Ileum, cecum, appendix, lower end of the ileum, right and left
Suprapubic ureter, right and left spermatic cord in males, right and left ovary
in females, uterus (in pregnant), urinary bladder, sigmoid

Right Upper Quadrant (RUQ) Left Upper Quadrant (LUQ)

Intraperitoneal: Intraperitoneal:
▪ Liver ▪ Left lobe of liver
▪ Gallbladder ▪ Spleen
▪ Pylorus ▪ Stomach
▪ Duodenum ▪ Splenic flexure of colon
4 QUADRANT METHOD

▪ Hepatic flexure of colon ▪ Portion of transverse and

▪ Portion of ascending and transverse descending colon
colon Retroperitoneal:
Retroperitoneal: ▪ Body of pancreas
▪ Head of pancreas ▪ Left adrenal gland
▪ Right adrenal gland ▪ Left kidney
▪ Portion of the right kidney
Right Lower Quadrant (RLQ) Left Lower Quadrant (LLQ)
Intraperitoneal: Intraperitoneal:
▪ Cecum ▪ Portion of descending colon
▪ Appendix ▪ Sigmoid colon
▪ Bladder (if distended) ▪ Bladder (if distended)
▪ Left ovary, left salpinx ▪ Left ovary, left salpinx
▪ Uterus (if enlarged) ▪ Uterus (if enlarged)
Retroperitoneal: Retroperitoneal: Point of reference in cross section: Umbilicus
▪ Lower pole of the right kidney ▪ Left spermatic cord
▪ Right spermatic cord ▪ Left ureter
▪ Right ureter

Right Hypochondriac Epigastric Left Hypochondriac

Right lobe of liver, Pyloric end of stomach, Stomach, spleen, tail of
gallbladder, part of duodenum, pancreas, pancreas, splenic
duodenum, haptic flexure of colon, upper
9 REGION METHOD

aorta, portion of liver

flexure of colon, part of pole of left kidney,
right kidney, suprarenal suprarenal gland
gland
Right Lumbar Umbilical Left Lumbar
Ascending colon, lower Omentum, mesentery, Descending colon
half of the right kidney, transverse colon, lower ,lower half of the left
part of duodenum and part of duodenum, kidney, part of jejunum
jejunum jejunum and ileum and ileum
Right Iliac Hypogastric or Pubic Left Iliac
Cecum, appendix, lower Sigmoid colon, left ureter,
end of ileum, right ureter, Ileum, bladder, uterus left spermatic cord (male),
right spermatic cord (pregnant) left ovary (female)
(male), right ovary
(female)

MENDOZA, RD (May2021)
 PE sequence: I – A – P – P [INSPECTION, AUSCULTATION, PERCUSSION, PALPATION]

INSPECTION

CONTOURS SYMMETRY SKIN FINDINGS UMBILICUS VISIBLE PERISTALSIS VISIBLE PULSATON

Flat, Symmetrical Striae, Discoloration Flat
Scaphoid or Concave, Asymmetrical Scars, Everted
Protuberant/ Rounded/Convex, Dilated Veins,
Any Abnormal Bulges Ecchymosis of the Abdominal Wall skin In The Flanks
(Grey Turner’s Sign),
Ecchymosis In The Periumbilical Area (Cullen’s Sign)

SPECIFIC FINDINGS AND SIGNIFICANCE

CONTOUR SYMMETRY
Distention of the Distended Lower Asymmetric
CONTOUR SYMMETRICAL CONDITIONS
Upper Half half/ Lower third Distention
Flat Well-muscled, athletic Fatal tumor Full bladder Hernia
Scaphoid or concave Thin adults, malnutrition (gastric, pancreatic) Fetus Feces
Generalized distention (rounded/ Fat (obesity) Fibroids (ovarian/ Cyst
convex/ protuberant) with inverted Flatus (gas distention) Fluid False tumor (gastric uterine) Tumors
umbilicus (ascites) dilation, pancreatic cyst) Bowel obstruction
Fibroids (ovarian/ uterine) Enlarged organ
Generalized distention (rounded/ Fluid (chronic ascites of any etiology)
convex/ protuberant) with everted Fibroids (ovarian/uterine) Umbilical hernia
umbilicus

SKIN FINDINGS
VEINS SCARS
Usually not observed Spider Angiomata Indicative of Previous Surgery or Trauma.
Chronic Liver Disease/ Cirrhosis
→ Above the umbilicus
● Right Subcostal incision: cholecystectomy
▪ Obstruction is above towards the head
(most commonly the liver) ● Midline incision: exploratory laparotomy
▪ May indicate portal hypertension ● Paramedian incision: explorative
→ Below the umbilicus laparotomy
▪ Obstruction is below, down to the feet ● Inguinal incision: hernia repair
▪ May indicate problems in the iliac ● Right lower quadrant incision:
vessels Appendectomy
● Suprapubic incision: caesarian section,
other lower abdominal surgery

CULLEN SIGN GREY TURNER’s SIGN STRIAE

Acute Pancreatitis, Hazing; 100% Mortality rate Acute Pancreatitis Previous Globular Abdomen = Damaged Elastic Tissue

UMBILICUS
Centrally located, Slightly Normal Abdominal Aortic Aneurysm
Protruded/Inverted PULSATION Normal in thin individual; Abnormal in Hyperstenic

Nodular (Sister Mary Joseph Nodes) Metastatic Carcinoma, Intestinal Obstruction

PRESITALSIS
Hyperactivity of Bowel
Everted Hernia Ascites (d/t INC pressure intraabdominally)
Umbilical Hernia Supine: less prominent (intestine is deeper) STIGMATA OF LIVER CIRRHOSIS
Standing up/sitting down: more prominent
DUPUYTREN’s
(intestine protrudes) SPIDER ANGIOMA PALMAR ERYTHEMA
CONTRATCURE

MENDOZA, RD (May2021)
 AUSCULTATION

BOWEL SOUNDS BRUITS

● Clicks and gurgles are normally heard at irregular rate of 5- 35/min ● In areas with turbulent or increased blood flow
● Borborygmi = Capillaria philippinensis ● Implication of occlusive vascular disease or an increase in blood flow especially if
heard during both systole and diastole
● Use diaphragm of stethoscope
HYPERACTIVE HYPOACTIVE
(increased) (decreased to silent) BRUITS LOCATION
Hunger Peritonitis (with tenderness of From the aorta Midline above umbilicus
Diarrhea abdomen & not seen in ileus) Left Renal arteries 3 or 4 cm left lateral
Gastroenteritis Right Renal arteries 3-4 cm right lateral and above the umbilicus
Ileus (peristalsis has stopped)
Early intestinal obstruction Left Iliac arteries over the left lateral area below the umbilicus
- Increased peristalsis No abdominal tenderness Intestinal Right Illiac arteries over the right lateral area below the umbilicus
obstruction (might need surgery)
- Emergency Femoral arteries Inguinal areas
HIGH PITCHED TINKLING
Early intestinal obstruction
Partial obstruction (with abdominal cramp, intestinal fluid and air under
tension)

OTHER FINDINGS
Increased collateral between portal and systemic venous
system = PORTAL HYPERTENSION
VENOUS HUM ● Softens when jugular vein is pressed
● Disappears when patient turns to one side
FRICTION RUB Inflammation of Peritoneum (Pleuritis), Tumor, Or Infarct
Test for Gastric Outlet Obstruction
● Intestinal or pyloric obstruction due to pyloric
stenosis or gastric carcinoma
SUCCUSION SPLASH ● If with significant epigastric pain: gastric outlet
obstruction secondary to ulcer
● With anemia: ulcer or tumor in stomach
● Chronic abdominal pain: stricture related to PUD
FLUID SHIFTING Fluid and air in abdomen = ASCITES
DULLNESS

PERCUSSION

PERCUSSION NOTES IN ABDOMINAL CAVITY LIVER VS. SPLEEN

TYMPANITIC DULL LIVER SPLEEN
Hollow, high, drum- like sound; has a Short high pitch note with little Normal: Dull Above: Resonant Cannot be normally identified unless
higher pitch than resonance resonance Below: Tympanitic enlarged
Gastric air bubble Normal abdominal Solid organs (e.g. liver, spleen) Normally CANNOT palpate spleen in the
cavity Abdominal mass 1-2 fingerbreadths below the R Traube’s space (9th LICS AAL)
Distended urinary bladder in subcostal margin in the MCL Castell’s Sign: dullness upon percussion; sign
hypogastric area of splenomegaly
Impacted stool SIZE:
Ascites 6-12cm MCL
4-8cm midsternal line
60-70% accuracy with actual span

OTHER FINDINGS
ASCITES
FLUID → Increased hydrostatic pressure
▪ Liver cirrhosis, heart failure, constrictive pericarditis, or
SHIFTING inferior vena cava or hepatic vein obstruction
DULLNESS → Decreased osmotic pressure
▪ Nephrotic syndrome, malnutrition, ovarian cancer

FLUID WAVE ASCITES

Most sensitive way of

PUDDLE SIGN testing for ASCITES

MENDOZA, RD (May2021)
 PALPATION

LIVER PALPATION
CONVENTIONAL METHOD HOOKING METHOD
• Palpate by placing right hand well below the lower border of the • Hook the right costal margin of the patient by pressing your fingers of both
liver dullness hands in and up toward the right costal margin
• Press hand gently in and up • Instruct the patient to take a deep breath and feel the liver edge as it
• Instruct the patient to take a deep breath and feel the liver edge as descends to meet the hooked fingers
it comes down to meet the palpating fingertips • Describe the liver edge and surface (note the sharpness of the liver edge and
• Evaluate liver edge and surface report any nodularities or tenderness)

SPLEEN PALPATION
• Place the patient in a supine position with knees flexed or right lateral decubitus position
• Reach across with your left arm placing your left hand beneath the patient over the left costovertebral angle (CVA) or left flank.
• Press left hand upward anteriorly toward the abdominal wall.
• Press your right hand below the left costal margin Instruct the patient to take a deep breath and feel the edge of the spleen as it comes down to meet your
fingertips.

DIRECT RECTAL EXAMINATION

• Explain procedure to the patient
• Instruct the patient to assume left lateral decubitus position, extend
patient’s left leg and flex right leg at the hip and knee joints
• Drape patient appropriately
• Wear gloves on both hands
• Inspect perianal area for skin tag, skin lesions, external hemorrhoids,
lumps, opening of fistula
• Perform digital examination:
o Lubricate entire index finger
o Insert lubricated finger gently into the anal canal pointing
toward the sacrum initially, before inspecting the whole
circumference
o Note for the anal sphincteric tone
o Palpate anus on 4 quadrants and note for masses, tenderness,
internal hemorrhoids, prostate (males) – size, consistency,
tenderness, nodule; cervix (female); blood on examining
finger, color of stools
• Wipes perianal area after examination

OTHERS

MURPHY’s SIGN CAPUT MEDUSAE

Pain upon palpation on right subcostal level after inhalation = (+) Portal Hypertension, check for possible
(+) CHOLECYSTITIS

Link of Video Demo

ASTERIXIS YELLOWING OF SCLERAE

Involuntary flapping of the wrist = (+) UREMIA (+) Jaundice

Link of Video Demo

MENDOZA, RD (May2021)
 ULTRASONOGRAPHY

LIVER and RIGHT KIDNEY PANCREAS

HEPATIC VASCULATURE GALL BLADDER

SPLEEN ABDOMINAL AORTA

Click HERE for more UTZ examples

MENDOZA, RD (May2021)