MEDICINE

1: FINAL PRACTICAL EXAMINATION

REMEMBER:

SEATED

GENERAL SURVEY, VS, SKIN, HEENT, NECK,

PULMO

Patient sitting, examiner in front

Patient sitting, chest exposed, examiner goes in

front then back

SUPINE

CARDIO, GIT, GUT

Patient supine, chest exposed, examiner at right

side of patient

Patient at 30 or 45 degree angle, chest exposed,

examiner at right side

Patient supine, abdomen exposed, examiner at

right

STANDING

NEURO, MUSCULO

Patient standing, examiner in front, then at the side

of the patient

Always state your findings

Height and weight of the patient will be provided to

you

Bring a calculator for BMI calculation

Prepare your materials before starting examination

PREPARATION:

Wash hands before and after the examination

Introduce self to patient

Explains what will be done to the patient

Ask if the patient would like to use the restroom

Ensure privacy and patients comfort throughout the

examination

Ensure adequate lighting and exposure

Materials are complete and prepared beforehand

No borrowing of instruments except for diagnostic

set

Examiner speaks in professional manner

No jargon or inappropriate language

A. GENERAL SURVEY

State of health

Well, acutely ill, chronically ill

Level of consciousness

Conscious, sedated, drowsy

I
Confusion
Inappropriate response to a question
Decreased attention span and memory
II Lethargy
Drowsy, falls asleep quickly
Once aroused, responds appropriately
III Delirium
Confusion with disordered perceptions and
decreased attention span
Marked anxiety with motor and sensory
excitement
Inappropriate reactions to stimuli
IV Stupor
Arousable for short period to verbal,
painful stimuli
Simple motor and moaning responses
Slow responses
V Coma
Neither awake nor aware
Decerebrate posturing to painful stimuli

Eye opening
4
Spontaneous
3
To speech or verbal stimuli
2
To pain
1
None or no response
Best verbal
5
Oriented to appropriate stimuli
response
4
Confused speech
3
Inappropriate words
2
Incomprehensible (incoherent)
1
None
Motor response
6
Obeys commands
(of unaffected limb) 5
Localizes painful stimuli
4
Withdrawn from pain
3
Arm flexion to painful stimuli
2
Arm extension to painful stimuli
1
None

Glasgow coma scale

Habitus
Hyposthenic
Ectomorphic

Sthenic

Mesomorphic

Hypersthenic

Endomorphic

Tall, thin, long neck

Poor muscle dvlpt.
Small bone structure
Appears malnourished
Ultrafast metabolism
Athletic type
Broad shoulders
Great muscle dvlpt.
Large bone structure
Low body fat %
Fast metabolism
Short, stocky
Thick and short neck
Good muscle dvlpt.
Obesity tendencies

Comfort

State if patient is comfortable or in RESPIRATORY

DISTRESS
Abdominal paradox
Central cyanosis
Altered sensorium
Prefers upright or tripod position
Prominent SCM
Retractions
Speaks in phrases
Ambulatory status

Ambulatory

With assistance

Wheel-chair

Stretcher

Bedridden
Mood

Attitude towards the examiner

Cooperative
Guarded
Suspicious
Evasive
Hostile
Seductive

Predominant mood
Neutral
Anxious
Fearful
Elated
Euphoric
Angry
Depressed
Irritable

Affect
Broad
Restricted
Labile
Intensity (blunted, flat, animated)

Appropriateness
Facies

B. MENTAL STATUS

Attention/calculation

Remember 3 words or simple math question

Time: Do you know the current date?

Place: Do you know the name of this hospital?

Person: State full name / birthday.

MEDICINE 1: FINAL PRACTICAL EXAMINATION

C. VITAL SIGNS

Patient needs to be resting for 5 minutes

Ask for intake of caffeinated drinks, smoking, alcohol,

antihypertensive meds, NSAIDs, steroids.

Note time and amount of last intake

Patient is instructed to avoid smoking, drinking for

30 minutes before BP is taken

Reminders:

Patients arm at rest so that the brachial artery is at

heart level (approx. 4th ICS)

If supine, position patient at 30-45 angle

If standing, support the arm at mid chest level

If seated, rest arm on a table a little above the

patients waist

Stay on the RIGHT SIDE of the patient in taking the

blood pressure on the right upper extremity (left
side for left upper extremity)

Use index fingers to palpate for the patients

brachial and radial arteries

Use the proper width of the inflatable bladder

40% or 12-14cm of the upper arm
circumference
Length should be 80% of the upper arm
circumference, along long enough to encircle
the arm

Apply the cuff 2.5 cm above the antecubital fossa

Ensure that the center of the inflatable bladder of

the BP cuff is over the brachial artery

Wrap the cuff snugly

Be able to insert only one finger underneath
the cuff

Measure palpatory BP correctly

Use index and middle fingers to palpate the radial

artery

With the other hand, rapidly inflate cuff while

palpating radial artery pulse

Note when the pulse disappears

State palpatory (SYSTOLIC) BP

Deflate cuff

Measure auscultatory BP correctly

Wait 15-30 seconds after getting the palpatory BP

Palpate for the brachial artery again using index

and middle fingers

Apply the BELL of the stethoscope over the

brachial artery

Inflate BP cuff rapidly 30 mmHg ABOVE the

palpatory (SYSTOLIC) BP

Slowly deflate BP cuff by 2-3 mmHg/sec

First Korotkoff sound = auscultatory (SYSTOLIC)

BP (N.V. 120)

When the Korotkoff sound disappears = DIASTOLIC

BP (N.V. 80)

If elevated measure BP, on other arm and leg

Adult BP classification (ages 18 and older)
Classification
Systolic
Diastolic
(mmHg)
(mmHg)
Normal
<120
<80
Pre-
120-139
80-89
hypertensive
Stage 1
140-159
90-99
Stage 2
>160
>100

Palpate for the patients radial pulse

Use index and middle fingers to palpate for the

patients radial pulse

Count the pulse rate for ONE FULL MINUTE

Note the pattern (rhythm)

Regular, irregular, irregularly irregular

Note the volume

N.V. 60-100 bpm regular +2

No pulse
Absent, not palpable
(-)
Weak pulse
Diminished, barely
(+)
palbable
Normal pulse
Expected
(++)
Strong pulse
Full, increased
(+++)
Very strong
Bounding,
(++++)
pulse
aneurysmal

Pulsus
- Alternation of pulsation
Left ventricular
alternans
of small amplitude with
failure
the pulsation of large

amplitude
(more significant if
- Rhythm is regular
pulse is slow)
Pulsus
- Best detected by
Aortic stenosis
bisferiens
palpation of the carotid
combined with aortic
artery
insufficiency
- Characterized by two
main peaks
- The first is termed
percussion wave which is
believed to be the pulse
pressure and the second
is called the tidal wave
which is the reverberation
from the periphery
Bigeminal
- Result from a normal
Disorder of rhythm
pulse
pulsation followed by a
PVCs
premature contraction
- The amplitude of the
pulsation of the
premature contraction is
less than that of the
normal pulsation
Large,
- Also called hyperkinetic
Exercise
bounding
or strong pulse
Anxiety
pulse
- Readily palpable
Fever
- Does not fade out and
Hyperthyroidism
is not easily obliterated by Aortic rigidity
the examining fingers
Atherosclerosis
PDA
Pulsus
- Characterized by
Premature cardiac
paradoxus exaggerated decrease (>
contraction
10 mmHg) in the
Tracheobronchial
amplitude of pulsation
obstruction
during inspiration and
Bronchial asthma
increased amplitude
Emphysema
during expiration
Pericardial effusion
Constrictive
pericarditis
Water-
- Also known as collapsing Patent ductus
hammer /
pulse
arteriosus
Corrigan
- Has greater amplitude
Aortic regurgutation
pulse
than expected
- A rapid rise to a narrow
summit, and a sudden
descent
Labile
Increase amplitude in
Non-specific
pulse
sitting and standing
compared to supine

MEDICINE 1: FINAL PRACTICAL EXAMINATION

Determine respiratory rate in a subtle way

With the patient unaware, RR is determined in a

subtle way by pretending to continue counting
pulse rate and note the number of rise/fall (cycles)
of the chest for 1 full minute and pattern if any

N.V.
12-20 respirations/breaths per minute
The ratio of respirations to heartbeats is 1:4
Expansion of the chest should be bilaterally
symmetric
The pattern of breathing should be even,
neither too shallow or too deep

Measure BMI

BMI = Wt (kg) / Ht (m2)

<18.5
Underweight
18.5 24.9
Healthy
25 29.9
Overweight
>/= 30
Obese
30 34.9
Class 1 Obesity
35 39.9
Class 2 Obesity
>40
Class 3 Obesity

D. SKIN

Prepare penlight and ruler

Color

Presence of discoloration, (table 8-3, p. 162)

Texture

Smooth, rough?

Moisture

Minimal perspiration, oiliness

Primary lesions (table 8-4, pp. 166-168)

Flat, non-palpable
Macule: <1cm
Patch: >1cm
Just epidermis, superficial, usually just
discolorations

Elevated, palpable
Papule: <1cm
Plaque: >1cm
Nodule: >1cm, deep on palpation, big, out
Tumor: > 2cm, big, out/in, deep palpation

Fluid filled
Vesicle: <1cm
Bullae: >1cm
Pustule: purulent material inside

Secondary lesions (table 8-5, pp. 169-171)

Scales: laminated masses of keratin, dead skin,

corneum

Crust: dried serum, pus or blood mixed epithelial

debris and sometimes bacterial debris

Fissure: linear crack through epidermis or into

dermis

Erosion: loss of all or part of epidermis alone

Ulcer: loss of epidermis and some portion of

dermis, heal with scarring

Scars: connective tissue replaced lost substance in

dermis or deeper keloidal scars

Excoriation: loss of epidermis, linear hallowed-out

crusted area

Keloid: irregularly-shaped, elevated, progressively

enlarging scar, grows beyond the boundaries of the
wound: caused by excessive collagen formation
during healing

Lichenification: rough, thickened epidermis

secondary to persistent rubbing, itching or skin
irritation, involves flexor surface of extremities

Other respiratory patterns
Bradypnea
Slower than 12 breaths per minute
Neurologic or electrolyte disturbance,
infection, response to point of pleurisy or
irritative phenomena, meidcations, deep
sleep
Tachypnea
Faster than 12 breaths per minute
Heart or lung disease, pain
Hyperventilation
Faster than 20 breaths per minute, deep
Hyperpnea
breathing
Protective splitting from a broken rib or
pleurisy, massive liver enlargement,
abdominal ascites, exercise, anxiety, CNS
and metabolic disease
Sighing
Frequently interspersed deeper breath
Normal if occasional, anxiety if frequent
Air trapping
Increasing difficulty in getting breath out
Hypopnea
Shallow respirations
Cheyne-stokes
Varying periods of increasing depth
interspersed with apnea
Periodic breathing, sleep in kids and
elderly, seriously ill, brain damage at
cerebral level, durgs
Kussmaul
Rapid, deep, labored
Metabolic acidosis
Biot
Irregularly interspersed periods of apnea in
a disorganized sequence of breaths
Severe & increased intracranial pressure,
respiratory compromise, drug poisoning,
brain damage at the level of medulla
Ataxic
Significant disorganization with irregular
and varying depths of respiration
Stridor
Harsh, high-pitched inspiration
Danger: airway obstruction

Take the temperature

Remember
Rectal: 0.4C > oral temperature
Tympanic membrane: 0.8C < rectal
temperature
Axillary: 0.5C < oral temperature
Ergo: rectal > oral > axillary > tympanic in
approximating core body temperature

Mean oral temperature: 36.8C + or 0.4C

Normal circadian range: 36.5-37.5C

Normal daily temperature variation: 0.5C

AM: 37.2C
PM: 37.7C
Mild/low grade fever
38.1 39C
Moderate grade fever
39.1 to 40C
High grade fever
40.1 to 41.1C
Hyperpyrexia
>41.5C
Acute fever
<7 days
Subacute fever
>7 days to <2 weeks
Chronic/persistent fever
> 2 weeks

Press on the button, remove clothing from the

axilla, place the tip of the thermometer underneath
the axilla

Instruct patient to firmly appost the medial aspect

of the arm to the lateral surgace of the chest to
keep the thermometer in place

Wait for the alarm and read the temperature

MEDICINE 1: FINAL PRACTICAL EXAMINATION

E. HEENT

Inspect and palpate head and scalp systematically

Head position: tilted, tremor

Size, shape (molding), symmetry, lesions, trauma

Facial features
Associated disorders
Cushings syndrome
Moon-facies, thin erythematous skin,
buffalo hump
Hippocratic facies
Sunken appearance of the eyes, cheeks
(throat cancer)
and temporal areas, sharp nose and dry
rough skin
Myxedema facies
Dull, puffy, yellowed skin, coarse sparse
hair, temporal loss of eyebrows,
periorbital edema, prominent tongue
Hyperthyroid facies
Fine, moist skin, fine hair, prominent
eyes and lid retraction, staring or
startled expression
Systemic lupus
Butterfly-shaped rash over mala
erythematous
surfaces and bridge of the nose
Either a blush with swelling or scaly,
red, maculopapular lesions
Bells palsy
Left facial palsy, asymmetry of one side
of the eyelid not closing completely,
drooping lower eyelid and corner of
mouth, loss of nasolabial fold
Acromegaly
Coarsening of features with broadening
of nasal alae and prominence of the
zygomatic arches

In examining the scalp, systematically part the hair

from frontal to occipital region
Note any lesions, scabs, tenderness, parasites,
nits or scaliness
Pay special attention to the areas behind the
ears, the hairline and at the crown of the haid
Note any loss pattern

Palpate in a gentle rotary movement progressing

systematically from front to back

Inspect for position and alignment of

Eyebrows
Wrinkle forehead, raise your eyebrows
Loss, odd hair, presence of seborrhea

Eyelids
Close eyes tightly: fasiculations or tremors
OPEN EYE: superior eyelid should cover a
portion of the iris but not the pupil itself
The average upper eyelid position is 2mm
below the limbus
The average lower eyelid position is at the
lower limbus
Note whether the lids evert or invert

Eyes
Symmetry, size and shape

Inspect abnormalities of conjunctivae and sclera

Have the patient look upward while you draw the

lower lid downward

Using a penlight, inspect sclera and conjunctive of

lower eyeball for color, swelling and vascularity

Inspect the upper tarsal conjunctiva only when

there is a suggestion that a foreign body may be
present

Observe the conjunctiva for erythema or exudate

Eythematous / cobblestone: allergic infectious
conjuctivitis

Test for visual acuity (central vision)

Using Snellen chart or pocket card (CNII)

Test one eye at a time initially without correction

(sc) then with correction (cc)

Position patient 20 ft. from Snellen chart or ask

patient to hold pocket card 14 in. away

Instruct patient to cover one eye with card or palm

of the hand

Ask patient to read each line down to the smaller

characters

Record visual acuity as fraction

Check conjugate extra ocular movements (CN III, IV, VI)

Instruct patient to follow your index finger with

their eyes only and with the head remaining in one
position

Move your index finger slowly to the extreme

position of each of the 6 cardinal fields of gaze (H-
pattern)

Test pupils for reactivity to light

Both directed and consensual as well as

accommodation (CN II, III)

Direct reaction
Check for pupillary constriction in the eye that
light is shined into

Consensual response
Dim light in the room
Instruct patient to look into distance and not
to focus on the light
Shine a penlight into one eye from a point
slightly lateral to the patients line of vision
Note whether the pupil constricts
Note the consensual response of the opposite
pupil constricting simultaneously with the
tested pupil
Repeat steps for the other eye

Accommodation response
Instruct patient to look at a distant object and
then at the test object (pencil or your finger)
held 10 cm from bridge of patients nose and
check for pupillary constriction when
changing focus from distance object to test
object
Do an ophthalmic examination

Darken the room

Set ophthalmoscope at correct setting

Use with ease and dexterity

Instruct patient to fix eye on specific point in the

distance and try not to move eyes

Use opthalmoscope in RIGHT HAND and look

through it with RIGHT EYE to examine PATIENTS
RIGHT EYE (if left hand, left eye, patients left eye)

Shine beam into eye from position approximately

12 inches from the patient and about 15 degrees
lateral to patients line of vision

Note orange glow in pupil, red reflex from retina

and opacities interrupting red reflex

Move closer to patients eye to examine retina,

optic disc, retinal vessels, peripheral retina and
macular area

Describe disc margin, cup/disk ratio, A:V ratio,

absence/presence of hemorrhages, exudates,
cotton wool, spots, copper wiring, AV nicking

MEDICINE 1: FINAL PRACTICAL EXAMINATION

Check hearing acuity in each ear

Whisper test / watch ticking

Ask patient to occlude each ear one at a time with

his/her finger
Inspect and palpate external ear for deformities and
tenderness

Inspect and palpate auricle and surrounding

tissues for deformities, masses, skin lesions,
tenderness

Gasps top of pinna correctly to straighten canal

(upward and backwards)
Perform otoscopic exam properly

Inspect ear cannal with otoscope speculum for wax,

discharge, foreign bodies, redness and swelling
Inspect nose structure, nostril patency, septum position,
inflammation of nasal mucosa

Visually inspect/palpate nose for deformity,

symmetry, inflammation

Elevate tip of nose with the neck hyperextended

Bilaterally inspects nasal mucosa

Inspect nasal septum

Tilt patients head back slightly and inspect the

inferior and middle turbinates and nasal passage
Palpate for tenderness of the frontal, ethmoid and
maxillary sinuses

If tender, do trans-illumination

Apply digital pressure with the thumb and index

finger over the bony brow sides of the nasal bone
as well as the cheek bone to palpate for tenderness
Inspect mouth

Lips
Color, symmetry, inflammation

Gums, teeth, tongue, floor of the mouth and

posterior pharynx
Instruct patient to open mouth
With tongue blade and penlight, visually
inspect teeth, tongue, hard and soft palate,
gums, floor of the mouth and buccal mucosa
Ask patient to protrude tongue and inspect for
deviation and limitation of movement
Using gloves, wrap tongue with a piece of
gauze and gently pulls tongue to each side and
inspect its lateral borders
Check for lumps, nodules and ulcerations
Instruct patient to say ah and inspect
pharynx including soft palate, uvula
Note for deviation of uvula
Touch the posterior wall of the pharynx with a
tongue blade and elicit gag reflex
Neck

Instruct patient to relax, with neck flexed slightly

forward or to side being examined and inspect
neck for symmetry and masses

Examine for palpable lymph nodes at occipital, pre

and post auricular, submandibular, submental,
ant/post cervical and supraclavicular areas
Using pads of first two fingers, move skin over
underlying tissue in a rotary mtion

With patient swallowing, palpate thyroid tissue

correctly for size, symmetry, consistency
Ask patient to gently extend neck
Stand either in front or behind the patient
Bimanually palpate thryroid gland pushing
gently to the right with the first two fingers of
the LEFT HAND
Palpate RIGHT LOBE when the patient
swallows
Auscultate for bruit

Assess whether trachea is midline

Face the patient
Inspect the position of the trachea
Insert index fingers on the spaces on either
side of the trachea
Normal: spaces on either side of the trachea
are equal, trachea is midline

F. THORAX, LUNGS

Describe the configuration of anterior chest

Note for deformities of the chest

Symmetry
Chest asymmetry: unequal expansion and
respiratory compromise caused by collapsed
lung or limitation of expansion by extrapleural
air, fluid or mass

Masses

Bulges
Unilateral or bilateral bulging can be a
reaction of the ribs and interspaces to
respiratory obstruction

Scars

Lesions

Compare AP to lateral chest diameter

Normal: AP diameter is less than the lateral

diameter

Identify the sternal angle of Louis and count the spaces

anteriorly

Assess symmetry of lung expansion (inspection and

palpation)

Face the patient

Place thumb along costal margins and xiphoid

processes with palms resting on the anterior chest

Ask patient to take deep breath

Observe for movement of hands

Describe if anterior chest wall movement is

symmetrical or asymmetrical

Move towards back of patient

Locate inferior angle of scapula (7th ICS)

Palpate for the 10th ICS along midscapular line

Puts both palms flush against the chest wall along

the 10th ICS

Grasp the posterior chest and moves both hands

medically (towards the vertebral line) so as to form
a crease along the mid-back

Ask the patient to take a deep breath

Observe for movement of hand

Describe if posterior chest wall movement is

symmetrical or asymmetrical

Palpate for any tenderness in the chest wall and

perform tactile fremiti

Palpate gently across anterior and posterior chest

Describe if there are any points of tenderness,

bulges, masses

Ask patient to cross his arms across his chest

Move toward back of patient

Rest ulnar surface of hand in the upper posterior

chest, medial to the scapula

Ask patient to say ninety-nine or tres-tres

Feel for vibration in the area

Move to other side and do the same procedure

Move hand to the lower position and do the same

procedure

Always compare one side to the other while

moving from upper to mid chest area, initially
always medial to the scapula

Once below the level of T7 or 7th ICS, examine

tactile fremiti along the scapular lines and
posterior axillary lines, always comparing one side
to the other

Normal: tactile fremiti are equal

Percuss anterior lung fields

Remind patient to keep his arms crossed

Beginning at the upper lung field, align finger (of

pleximeter hand) along intercostal space along the
paravertebral line

Make sure it is only the distal 3rd of the finger

resting on the chest wall

Strike the distal 3rd of the finger with the tips of the
fingers of the free hand (plexor)

Listen for percussion sound produced

Do same procedure from upper to the lower lung

fields

MEDICINE 1: FINAL PRACTICAL EXAMINATION

Percussion Tones Heard Over the Chest
Type of Tone
Intensity
Pitch
Duration
Resonant
Loud
Low
Long
Flat
Soft
High
Short
Dull
Medium
Medium Medium
Percussion over
to high
liver
Tympanic
Loud
High
Medium
Percussion over
abdomen
Hyperresonant
Very loud Very low Longer
Hyperinflation,
emphysema,
pneumothorax,
asthma

Breath sounds

Make sure the patient still has his arms crossed over his
chest

Ask patient to take slow deep breaths through his

mouth

Auscultate with the diaphragm of the stethoscope in the

same areas used in palpation and percussion

Moving from upper lung field to lower, always

comparing one side to another

Listen to 2-3 respiratory cycles before moving to next

position

State if there are adventitious breath sounds

Characteristics of Normal Breath Sounds
Vesicular
Heard over most of lung fields, low pitch,
breezy, soft and short expirations, more
prominent in a thin person or child,
diminished in overweight and very
muscular patient
Bronchovesciuclar Heard over main bronchus area and over
upper right posterior lung field, medium
pitch, expiration equals inspiration
Bronchial /
Heard only over trachea, high pitch, loud
tracheal (tubular)
and long expirations, sometimes a bit
longer than inspiration, coarse, loud

Adventitious Breath Sounds
Fine Crackles
High pitch, discrete, discontinuous
crackling sound heard during the
end of inspiration, not cleared by a
cough
Medium Crackles
Lower, more moist sound heard
during the midstage of inspiration,
not cleared by cough
Coarse Crackles
Loud, bubbly noise heard during
inspiration, not cleared by cough
Ronchi (Sonorous
Loud, low, coarse sounds like a
Wheeze)
snore most often heard
continuously during inspiration or
expiration, coughing may clear
sound (usually means mucus
accumulation in trachea or large
bronchi), more pronounced during
expiration
Wheeze (Sibilant
Musical noise, sounding like a
Wheeze)
squeak, most often heard
continuously during inspiration or
expiration usually louder during
expiration
Pleural Friction Rub
Dry, rubbing, or gating sound,
usually caused by inflammation of
pleural surfaces, heard during
inspiration or expiration, loudest
over lower lateral anterior surface

Quality
Hollow
Very dull
Dull thud

Drum like

Booming

Flat: over heavy

muscles, bones,
scapula, spinous
process

Resonant: upper
lung fields

Dull: viscera,
liver

Auscultate anterior lung

fields

Diaphragm of the
stethoscope is usually
preferable to the bell
for listening to lungs
because it transmits
the ordinary high-pitched sounds better and
because it provides broader area of sound

Place the stethoscope firmly on the skin

When the individual breath sound is being

evaluated, there should be no movement of patient
or stethoscope except for the respiratory excursion

To auscultate the back, ask the patient to sit as for

percussion with head bent forward and arms
folded in front to enlarge the listening area

Ask the patient to sit erect with shoulders back for

auscultation of anterior chest

Inspect back, cervical and

lumbar spine

Palpate each vertebral

process from cervical to
sacral
Identify the inferior angle of
the scapula and count the
interspaces posteriorly
Palpate any tenderness in
posterior chest wall
Test for tactile fremiti

Compare one side with another,

Test from top to bottom

Patients arms crossed in front

Perform percussion properly

Compare the percussion notes of both hemithorax

from top to bottom
Patients arms crossed in front
Auscultate the posterior thorax and compare one side
with another, test top to bottom

Check voice transmission

Compare one side with another

Patients arms crossed in front

MEDICINE 1: FINAL PRACTICAL EXAMINATION

G. JUGULAR VENOUS PRESSURE AND CAROTID PULSATION

Inspect neck veins and identify highest undulation of

the RIGHT INTERNAL JUGULAR VEIN and measure JVP
at 30 or 45 degrees angle

Position patient properly

Patient supine in bed, raise the patients head
slightly on a pillow
Raise the head of the bed about 30-45 degree
angle
Turn the patients head slightly towards the
left, exposing the right side of the neck

Use tangential white light over the right side of the

patients neck

Identify the right internal vein pulsation

Identify the highest point of the right jugular

venous pulsation

Measure the JVP

Identify the Sternal Angle of Louis by starting from

the suprasternal notch and slide finger down until
a hump is felt

Place a ruler graduated in cm vertically on top of

the Sternal Angle of Louis and extend another ruler
horizontally from the highest point of the jugular
venous pulsation perpendicular to the ruler on the
sternal angle

Note the vertical distance in cm above the Angle of

Louis at which the rulers intersect

State the JVP in cm water

Note the different waveforms of the JVP

Normal JVP: 3 cm at 30 degrees

Palpate for carotid artery pulse (once at a time) and

describe

Assess the right carotid artery pulse

With the patients head at midline, palpates for
the thyroid cartilage starting from the
submentum
Slide the index and middle fingers until a
prominent midline protrusion of the neck,
anterior to the trachea is felt
Gently slides fingers just below the thyroid
cartilage to the cricoid cartilage
With the other hand, turn the patients head
slightly to the right, and slides fingers laterally
from the cricoid cartilage to the groove
between the trachea and the right
sternocleidomastoid muscle
Feel the pulse, press and gradually releases
the right carotid artery pulse
Note the amplitude, contour and speed of the
upstroke and downstroke of the carotid pulse
Normal: Grade 2, pliable with rapid upstroke
and gradual downstroke

Assess the left carotid artery pulse

Same instructions but in the opposite
direction

Auscultate for carotid artery bruit, one at a time

H. CARDIOVASCULAR

Inspect the precordium and reports its dynamicity

Adynamic (normal), dynamic, hyperdynamic

At eye level, check for

Precordial bulging
Visible pulsations on the precordium

Look for the most lateral precordial pulsation

(apex beat)

Palpate the precordium and describe the apex beat

Palpates the apex beat by using the tips of the

right index and middle fingers

Describe the location of the apex beat

While palpating the apex beat, palpate for the
Angle of Louis with other hand
From the Angle of Louis, slide fingers laterally
to the left intercostal spaces
Count what intercoastal space the apex beat
is located
Using a graduated ruler (cm), note how far
away from the left midclavicular line and
from the midsternal line is the apex beat
found

Describe the diameter of the apex beat

Apply the tips of the fingers directly on top of
the apex beat
Note the number of fingers needed to cover
the apex beat
Describe the diameter of the apex beat in
fingerbreadths
Another method done by using a ruler
graduated in cm and measure the diameter of
apex beat in cm

Describe the amplitude of the apex beat

With fingertips, feel for the apex beat
Note the height of pulsation of the apex beat
whether normal or hyperdynamic (very
strong)

Describe the duration of the apex beat

While palpating the apex beat, auscultate for
the first and second heart sounds
Note the duration of systole
Note how much of systole does the apex beat
occupy
Normal duration: when the apex beat
occupies only up to half of systole
Sustained duration: when the apex beat
occupies almost the entire systole

Palpate for LV or RV heaves, LA lifts, PA lifts, abnormal

pulsations over 2nd ICS RPSL, and thrills

Palpate for heaves in the precordium

Using the heel of right hand, palpate for
abnormally strong pulsation
Left ventricular heave over the area of the
apex beat
Right ventricular heave over the left side of
the lower sternum

Palpate for lifts in the precordium

Using the fingertips, palpate for abnormal
pulsation over the
2nd ICS LPSL for pulmonary artery lift
2nd ICS RPSL for aortic artery dilatation
3rd and 4th ICS LPSL for left arterial lift

Palpate for thrills in the precordium

Using the ball of the hand, feel for fine vibratory
sensation over the different clinical valves
5th ICS, LMCL for mitral valve thrill, area of
apex beat
Left lower sternum for tricuspid valve thrill
2nd ICS LPSL for pulmonic valve thrill
2nd ICS RPSL for aortic valve thrill

MEDICINE 1: FINAL PRACTICAL EXAMINATION

Auscultate heart in the following areas: mitral,
tricuspid, pulmonic, aortic auscultatory valve areas
using diaphragm in an inching manner and note
character of S1 and S2 and high pitch murmurs if any

Using the Angle of Louis, locate and identify the

different auscultatory valve areas
5th ICS LMCL: mitral valve
Left lower parasternum: Tricuspid valve
2nd ICS LPSL: pulmonic valve
2nd ICS RPSL: aortic valve

Using the diaphragm of the stethoscope,

auscultate at the different auscultatory valvular
areas for the different heart sounds (either from
apex to base or base to apex in an inching manner)
1st heart sound in the mitral and tricuspid
area
2nd heart sound in the mitral and tricuspid
area
S1 louder at apex
1st heart sound in the aortic and pulmonic
area
2nd heart sound in the aortic and pulmonic
area
S2 louder at base
Note for the time interval between the 1st and 2nd
heart sounds (systole)
1st heart sound followed by the 2nd heart
sound
Note for the time interval between the 2nd and 1st
heart sounds (diastole)
Note for splitting of the 2nd heart sound especially
at the 2nd ICS LPSL
Inhalation

Maneuvers
Ask patient to assume a left lateral decubitus
position to accentuate heart sounds in the apical
area
Ask patient to lean forward to accentuate heart
sounds in the base
Shift to the bell and note for S3 and S4 and any low
pitch murmurs

Use the bell of the stethoscope

Auscultate for 3rd and 4th heart sounds at the

mitral and tricuspid valve areas

Use the diaphragm for high pitch and bell for the
low pitch sounds, auscultate for abnormal sounds
Note for turbulent sounds (murmurs) noted
during systole and diastole over the different
valvular areas
Note the character (high/low pitch), duration
of the murmur(s) and grading of the
murmur(s)
Slowly inch away and note the radiation of
the murmur

Maneuver
Vasalva Maneuver
Ask patient to take deep breath then hold,
pinch nose, close mouth and strains down
Carvallos Sign
Ask patient to inhale deeply while listening
for any change in the heart sounds

I. ABDOMEN

Instruct patient to relax, bend knees to relax abdomen if

needed and expose abdomen

Inspect abdomen

Skin characteristic
Striae, scars, spider angioma, dilated veins

Abdominal contour
Flat, scaphoid, protruberant, rounded

Symmetry
Symmetric, asymmetric

Pulsations
AAA, abdominal aortic aneurysm

Visible peristalsis
Thin person, obstruction

Umbilicus
Flat, everted

Hernias
Umbilical, inguinal

Auscultate abdomen

Bowel sounds
Use diaphragm
Normal: 5-35 per minute, normoactive
Absent: if nothing is heard after 5 minutes
Hypoactive: peritonitis, ileus
Hyperactive: gastroenteritis, hunger, early
obstruction
Borborygmi: loud and prlonged

Bruits
Use bell
Harsh, musical intermittent auscultatory
sound (turbulence)
Stenosis
Normal: none
Epigastric area: aortic, renal iliac, femoral
arteries RUQ LUQ costovertebral
angles liver

Friction rub
Fluid in pericardial activity
Over liver and spleen
High pitched, heard in association with
respiration
Inflammation

Percuss abdomen systematically in all 4 quadrants

Areas of tympanism
Stomach
Traubes space (left AAL, 9th ICS)

Areas of dullness
Liver
If there is splenomegaly, traubes space is dull

Percuss for liver dullness

Determine upper and lower border

Upper border: measure liver span along
RIGHT midclavicular line going down until it
changes from resonance to dullness
Lower border: percuss at RUQ below
umbilicus going up: note area of dullness
Percuss from lung resonance down to liver
dullness

Normal
Upper border (5th to 7th ICS)
Lower border (costal margin)
6-12 cm at midclavicular line
4-8 cm at midsternal line
5th to 7th ICD at midaxillary line

Percuss for splenic dullness over Traubes space in the

left AAL on deep inspiration

Percuss left lower anterior chest wall

Traubes space: 6th rib, midaxillary line, left costal

margin

Normal: tympanitic

Enlarged: dullness

MEDICINE 1: FINAL PRACTICAL EXAMINATION

J. NEUROLOGIC AND MUSCULOSKELETAL

Assessment of GCS

Test for motor coordination

Finger to nose test (full arm extension)

Ask the patient to first touch his nose with his
finger then touch your finger
18 inches away
If not normal, dysmetria

Alternate pronation/supination test

Test for balance/equilibrium

Rombergs test
Ask patient to stand with feet together, eyes
open and hands by the sides
Ask patient to close his/her eyes then observe
for a full minute for swaying
If (+), cerebellar ataxia

Tandem gait test

Ask patient to walk straight
Heel to toe walking

Examine trigeminal nerve functions: sensation to face

and muscles of mastication

Ask the patient to point to where you touch and ask

him/her to tell you if its light or sharp

Ask the patient to open his/her mouth/ protrude

his/her jaw, clench his/her teeth

Check muscles of facial expression

Eye closure

Forehead wrinkling

Eyebrow elevation

Smiling

CN VII

Test gag reflex and note elevation of palate

Touch the posterior wall of the pharynx with a

tongue blade and elicit gag reflex

CN IX and X

Ask patient to stick tongue and note whether its midline

during protrusion (CN-XII)

Test if shoulders are raised against resistance

Always compare right and left

0
No contraction, no movement
1
Fasciculations, flicker, trace of contractions
but no joint movement
2
Gravity eliminated
3
Against gravity but not against resistance
4
Moderate resistance
5
Maximum resistance, full power

Systematically palpate the entire abdomen

Do light palpation first then deep palpation while

looking at the face of the patient

Note any direct or rebound tenderness and any

masses and describe if present

Fingers together, flat on abdominal surface

Gentle dipping motion

Palpate and describe liver edge

Right hand well below lower border of liver

dullness

Press hand gently in and up

Ask patient to take deep breath and feel liver edge

as it comes down

Evaluate liver edge and surface

Normal: not felt

Thin, smooth, firm, even, nontender

Bimanual palpation of the spleen

Supine or lateral decubitus position for the patient

Left hand around and presses forward the left

lower rib cage

Right hand below the left costal margin towards

the spleen

Ask the patient to take deep breath and feel spleen

go down

Normal: not felt

Bimanual and bilateral palpation of the kidneys

RIGHT side of the patient for RIGHT kidney

Left side for left kidney

Hand behind patient below and parallel to the 12th

rib

Lift hand and displace kidney anteriorly

Other hand at upper quadrant, lateral and parallel

to rectus muscle

Ask patient to take a deep breath, at peak of

inspiration, press firmly and deeply in upper
quadrant below costal margin (capture kidney
between two hands)

Palpate kidney at expiration: slowly release

pressure of hand and feel for the kidney as it slides
back to its expiratory position

Normal: not painful, left kidney is not palpable,

right kidney is smooth, firm and non tender
Rectal examination

Patient in LEFT lateral decubitus position

Stretch the left leg, flex right leg

Inspect perianal area

Skin tags, lesions, external hemorrhoids,
lumps, opening of fistula

Digital examination
Gloves on the RIGHT hand, lubricate index
finger, insert gently into anal canal point
toward umbilicus
Note anal sphincteric tone
Palpate all 4 quadrants and note for mass,
tenderness, internal hemorrhoids, prostate
(size, consistency, tenderness), cervix, blood
on examining finger

Check motor strength of upper and lower extremities

and compare left and right sides including range of
motion

Tempomandibular joint
Protrusion, retrusion, lateral deviation of the
mandible

Shoulder joint
Forward flexion, extension, abduction,
adduction, external rotation, internal rotation

Elbow join
Flexion, extension, supination, pronation

Forearm, wrist and hand

Wrist flexion, extension
Radial/ulnar deviation of wrist
Finger flextion, extension
Finger abduction, adduction
Make a fist

Cervical
Flexion, extension, lateral flexion, rotation

Lumbar spine
Flexion, extension, lateral flexion, rotation

Hip joint
Flexion, extension, abduction, adduction,
external rotation, internal rotation

Knee joint
Flexion, extension

Ankle joint and foot

Dorsiflexion, inversion, eversion
Toe flexion, extension

MEDICINE 1: FINAL PRACTICAL EXAMINATION

Check sensory function of upper and lower extremities,
compare left and right sides

Light touch

Pain

Temperature

Vibration

Position
Check deep tendon reflex

Always compare left and right

Biceps (C5,6)

Triceps (C6, 7)

Patellar / knee jerk (L 2,3,4)

Ankle / Achilles (S2)

H. BONUS POINTS

Assessment of orthostatic hypotension

You take blood pressure readings with the patient

laying supine, sitting then standing

Wait three minutes between each reading

(+) any sign of a drop in 20 mm-Hg systolic BP and

10 mm-Hg diastolic BP plus an increase in pulse
rate of about 15 beats per minute

Vasalva maneuver

Ask patient to take deep breath then hold, pinch

nose, close mouth and strains down

Carvallos sign

Ask patient to inhale deeply while listening for any

change in the heart sounds

Murphys sign

Lie the patient supine (as you would during any

other abdominal assessment)

Instruct the patient to breath out

Place your palpating hand just below the costal

margin, approximately mid-clavicularly (this is just
above the gallbladder)

Then instruct the patient to slowly breath in;

(+) when the patient stops breathing in due to pain

Obturator test

(+) if pain is elicited on flexion of the hip and

rotation internally

Iliopsoas sign

Passively extending the thigh of a patient lying on

his side with knees extended, or asking the patient
to actively flex his thigh at the hip

(+) if there is abdominal pain

Shifting dullness

First the midline is percussed eliciting a resonant

note due to gas in the bowel
If there is no area of resonance then the test
cannot be performed

Percussion is then moved progressively more

lateral (away from the examiner) until the note
becomes dull

The examiner's index finger is left on the resonant

side, and the middle finger is left on the dull side

The patient is then asked to lean on their right

lateral side (assuming the examiner used the
traditional right sided approach)

Fluid wave

It is performed by having the patient (or a

colleague) push their hands down on the midline of
the abdomen

The examiner then taps one flank, while feeling on

the other flank for the tap

The pressure on the midline prevents vibrations

through the abdominal wall while the fluid allows
the tap to be felt on the other side

(+) if tap can be felt on the other side

I. SAY THANK YOU

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