DR. RUDRESH GENERAL
MEDICINE NOTES
Edited by: Arjun Patel
2016
Table of Contents
Case Sheet Writing
Pain and Fever
Abdominal Symptoms
CVS Symptoms
RS Symptoms
CNS Symptoms
Other History
General Physical Examination
Pulse, RR, BP
Peripheral Signs
Abdominal Examination
CVS Examination
RS Examination
CNS Examination
Abdominal Viva Questions
RS Viva Questions
CNS Viva Questions
CVS Viva Questions
2
3
5
7
11
13
14
16
21
23
25
30
33
37
47
55
62
69
1
Case Sheet Writing
Name
● Rapport
● Registration
Age: Particular diseases in certain ages
● Whooping cough (Children)
● Hypertension (Elderly)
Sex:
● Males: DM, HTN
● Female: Hyperthyroidism
● Males Only: BPH
Occupation
● Occupational Hazards (Nosocomial Hazards)
Address
● Follow Up
● Endemicity: Fluorosis, Elephantiasis, Cholera
Socio-Economic Status
● Kuppuswamy’s Classification
Chief Complaints
●
●
●
→
Systemic Diagnosis
Anatomical Diagnosis
Etiological Diagnosis
Example:
→
1. Fever - 3 Months
2. Cough + Sputum - 2
Months
3. Weight Loss
4. Evening Rise of
Temperature
Diagnosis
1. Respiratory
System
2. Chest
Examination
3. Probably TB
Example of Symptoms of Each System
Abdomen
CVS
RS
CNS
Pain Abdomen
Vomiting
Loose Motions
Jaundice
Distension
Anginal Pain
Palpitations
Breathlessness
Edema of Lower Leg
Cough
Pleuritic Pain
Cough
Breathlessness
Weakness
2
Pain
Duration
Site
Type
Aggravating Factors
Relieving Factors
Radiation
Associated Symptoms
Anginal Pain
Gastric Pain
Pleuritic Pain
Few Seconds to
Minutes
Retrosternal
Constricting
On Exertion
Hours to Days
Hours to Days
Epigastric
Burning
Spicy Food
Rest / Sublingual
Nitrate
Axilla and Back
Palpitations /
Sweating / Vomiting
Cold Foods / Antacids
Sides of Chest
Catching
Deep Respiration /
Cough
Lying on SAME
Side
No Radiation
Local Tenderness
No Radiation
Belching / Vomiting
Fever
●
●
●
●
Duration
Type
Chills/Rigors
Associated Symptoms
I
II
Types of Fever
I.
II.
III.
IV.
V.
VI.
VII.
Continuous Type
A. Fever does not touch baseline
B. Fluctuates less than 1℃
C. Example: Lung Abscess
Remittent Type
A. Does not touch baseline
B. Fluctuates more than 1℃
C. Example: Septicemia
Intermittent Type
A. Touches the baseline in 24 hours’
time
B. Example: Malaria
Step Ladder Type
A. Keeps increasing once in 2-3 days
B. Example: Enteric Fever
Pel-Ebstein Fever
A. Step ladder type for 6-8 days
B. Afebrile for 4-5 days
C. Then again step ladder type
D. Example: Hodgkin’s Lymphoma
Relapsing Fever
A. Relapse after one month
B. Example: Enteric Fever, Borrelia
Saddle-Type Fever
A. Within 4-5 days the fever comes back
B. Dengue, chikungunya
III
IV
V
3
Chills / Rigor
●
●
●
Set point in Hypothalamus is increased in fever
Body then feels chilly because the body temperature is of larger difference compared to the
environment
Rigors occur as the body tries to increase the body temperature by shaking
Causes
1.
2.
3.
4.
Malaria
UTI
Pneumonia
Lung Abscess
Associated Symptoms
1. Chills and Rigors
2. Burning Micturition
3. Cough and Sputum
4
Symptoms of the Abdominal System
1. Gastric Pain → Refer Above
2. Vomiting
○ Duration
○ Frequency
○ Contents → Bile, Blood,
Undigested Food
○ Projectile or Non-Projectile
○ Associated Symptoms →
Belching, Burping, Palpitations,
Sweating (MI)
Definition: Projectile Vomiting
● Sudden vomiting without nausea
● Seen in meningitis, brain tumors,
and other CNS disorders
⇌Differences between Hematemesis and Hemoptysis
Hematemesis
Hemoptysis
Vomiting of Blood
Acidic → From the Stomach
Dark in Color → Digested
Assoc. with Undigested Food Particles
Coughing up of Blood
Alkaline
Red → Directly from Capillary Rupture
May contain Sputum
5
Difference between Large and Small Bowel Diarrhea
3. Loose Motions
○
○
○
○
○
Duration
Frequency
Blood and Mucus
Consistency
Tenesmus
💭Tenesmus: Lower abdominal pain
with feeling of incomplete evacuation
of stool.
4. Jaundice
○
○
○
○
Duration
Progression
Itching
Stool Color
○ H/O
➢ loss of appetite
➢ vomiting
➢ generalized bleeding tendencies → deficiency
of clotting factors or vitamin K
💭Generalized Itching
● Feature of obstructive jaundice
● Pale or china clay colored stools also a
feature of obstructive jaundice
● Dark brown stools a feature of medical
jaundice
5. Distension of Abdomen
○ Duration
○ Onset
i.
ii.
Sudden
Gradual
→
○ Progression
○ Mode of Onset
→
○ Bleeding Tendencies
i.
ii.
iii.
For Portal hypertension
Hematemesis
Bleed per Rectum
○ Altered sleep rhythm
➢ Sleeps more in the daytime than night
➢ Earliest symptom of hepatic encephalopathy
○ Altered level of consciousness
➢ Drowsiness, Irritability, Coma → Also signs of
hepatic encephalopathy
Sudden Onset of Distension
1. Peritonitis
2. Perforation
3. Hemoperitoneum
Mode of Onset
1. Early morning face swelling then
abdominal distension → Renal
Pathology
2. Lower limb then abdominal →
Cardiac Pathology
3. First abdomen then lower limb →
Probably Liver Pathology
6
Symptoms of the Cardiovascular System
Right Heart Failure
1. JVP ⇑
2. Enlarged Tender Liver
Left Heart Failure
1. Cough
2. Pink Frothy Sputum
a. Due to stretched capsule
3. Edema of the Legs
4. Ascites
3. Breathlessness
4. 3rd/4th Heart Sound
5. Basal Crepitations
7
Symptoms
1. Anginal Chest Pain → Refer to Pain Chart
2. Palpitations
○
○
○
○
○
Duration
Fast or Slow?
Continuous or Intermittent
Post-Palpitation Diuresis
Associated Symptoms
i.
Syncopal Attack
ii.
Sweating
iii.
Breathlessness (LHF)
3. Edema of the Lower Limb
○ Duration
○ Onset
i.
Sudden
ii.
Gradual
○ Progression
i.
Up to Ankle
ii.
Up to Knee
iii.
Up to Hip
iv.
Generalized
○ Pitting or Non-Pitting
i.
Non-Pitting →
ii.
Pitting: Organ Failure
○ U/L or B/L
i.
U/L → DVT, Trauma, Cellulitis
○ Tender or Non-Tender
i.
Tender: DVT, Trauma, Cellulitis
○ Associated Symptoms
i.
Upper Abdominal Tenderness
ii.
Ascites
iii.
Reduced Urine Output
💭Palpitations: An undue and
unpleasant awareness of one's own
heartbeat which can be fast or
slow, continuous or intermittent.
💭Post-Palpitation Diuresis: Due to
secretion of Brain Natriuretic
Peptide (BNP) from the Left
Ventricle during left ventricular
systolic dysfunction → Aid in
diagnosis of CHF
Sudden Edema: Trauma and
Cellulitis
Gradual Edema: RHF and Liver
Failure
Non-Pitting seen in: Myxoedema,
Filariasis, Lymphatic Obstruction,
Angioneurotic Edema
?: Ask Patient if strap marks are
seen after removing slippers or
shoes
Reduced Urine Output: Backward
pressure on kidneys
8
History Taking of Cardiac and Respiratory Breathlessness
Cardiac - 7 Points
1) Duration
2) Onset
3) Progression
4) PND
5) Orthopnea
6) NYHA Grading
7) Associated Symptoms
4. Cardiac Breathlessness in Detail
1. Duration
2. Onset
○ Sudden → IHD
○ Gradual → Rheumatic HD
3. Progress
4. Paroxysmal Nocturnal Dyspnea
Respiratory - 9 Points
1) Duration
2) Onset
3) Progression
4) Seasonal Variation
5) Allergic Precipitation
6) MRC Grading
7) Wheeze is Predominant
8) Diurnal Variation
9) Associated Symptoms
PND: Patient is comfortable at
home, eats and sleeps with no
problem. In the middle of the
night the patient wakes due to a
feeling of choking, gets out of
bed and runs to a windows for
fresh air. The patient then feels
comfortable and returns to sleep.
○ Two Mechanisms:
1. During the day fluid in the extravascular
compartment is greater than the intravascular
compartment. When the patient sleeps the fluid in the the EVC shifts to the IVC and increases
blood return to the heart exacerbating heart failure. When the patient gets up to relieve the
pain, the fluid shifts back to the EVC reducing the load on the heart and relieving the
symptoms of PND.
2. Catecholamines are secreted at a higher degree in the night, therefore load to the heart is
increased due to vasoconstriction and tachycardia
9
5. Orthopnea
○ Definition: Breathlessness on lying down
○ Two Mechanisms
1. Blood return to heart increases when lying down, however standing up
reduces load due to peripheral pooling
2. The position of the diaphragm when lying down reduces lung compliance,
causing breathlessness
6. NYH Grading
I.
II.
III.
IV.
Dyspnea for Unaccustomed Work
Dyspnea for Accustomed Work
Dyspnea for Minimal Work
Dyspnea at Rest
7. Associated Symptoms
○ Cough, Pink Frothy Sputum, Chest Pain, etc.
10
Respiratory System Symptoms
1) Pleuritic Chest Pain – Refer to pain chart
2) Breathlessness
3) Cough
Respiratory Breathlessness
1. Duration
2. Onset
a. Acute → Status Asthmaticus, Foreign Body, Pneumothorax
b. Gradual
3. Progression
4. Seasonal → Usually exacerbated in the winter
5. Allergic Precipitation → Drugs, Food, Contact
6. Wheeze → Continuous, coarse, whistling sound on expiration, due to
bronchospasm
7. Diurnal Variation → Early morning and late night breathlessness
8. Associated  Ex: Relief with Inhaler
9. MRC Grading
0. No breathlessness, except with strenuous exercise
1. Breathlessness when hurrying on level ground or walking up a slight hill
2. Walks slower than contemporaries on level ground because of breathlessness, stops
for breath when walking at own pace
3. Stops for breath after walking about 100m or after a few minutes on level ground
4. Too breathless to leave the house, or breathless while dressing
11
Cough
Cardiac Cough
1) Duration
2) Onset
3)
4)
5)
6)
a. Sudden  MI
b. Gradual  RHD
Progress
Diurnal Variation  more in the evening
Postural Variation  Cough while lying down is much worse than sitting upright
Sputum  First it is frothy, then becomes pink due to capillary rupture
Respiratory Cough
1) Duration
2) Onset
3)
4)
5)
6)
7)
 Sudden  Foreign body, pneumothorax, pulmonary infarct
 Gradual  COPD
Progress
Diurnal Variation  Early morning and late night
Postural  Fine in supine, patient coughs more when turning to either side
Seasonal Variation  more in cold weather
Sputum production
 Quantity
i. More than 30 ml  copious
ii. More than 100 ml  bronchorrhea, seen in suppurative lung
diseases such as lung abscess and empyema.
 Quality
i. Mucoid  Bronchial asthma
ii. Mucopurulent  Bronchitis
iii. Rusty  Pneumococcal Pneumonia
iv. Pink Jelly  Klebsiella
v. Black/Dark  Coal Miner’s Pneumoconiosis
vi. Green/Yellow  Pseudomonas
vii. Anchovy Sauce  Ruptured lives abscess into lung
viii. Blood Stained  Hemoptysis
12
Central Nervous System
History
1) Duration
2) Onset
 A - Sudden  Cerebrovascular accident, Head trauma
 B - Gradual  Tumors (SOLs), Degenerative diseases
(motor neuron disease, Parkinsonism, hereditary
ataxia, Duchenne muscular dystrophy, amyotrophic
lateral sclerosis)
 C - Waxing and waning  Demylination and TIA,
Sudden onset, suddenly goes, and comes back just as
suddenly
3) Group of Muscles Involved
 Upper Limb
i.
Proximal: Lift hand above shoulder (combing)
ii.
Distal: Hold object (button shirt)
 Lower Limb
i.
Proximal: Difficult to stand (get up from squatting position)
ii.
Distal: Difficult to hold onto sandal
4) Raised ICP - Headache, vomiting, loss of consciousness, convulsions
5) Cranial Nerve Involvement
 CN I – Impaired Smell
 CN II – Blurry vision
 CN III, IV, VI – Diplopia
 CN V – Difficulty chewing food
 CN VII – Facial asymmetry
 CN VIII – Difficulty in hearing
 Cn IX, X – Difficulty in swallowing
 CN XI – Cannot shrug shoulder
 CN XII – Difficulty in speech
6) Sensory Problems - Tingling or Numbness
7) Bladder Involvement
 In UMN Lesion: Above the anterior horn cells excluding CN nuclei.
i.
The bladder tone is increased and it fills quickly with urgency felt sooner. The
patient will hurry to the toilet and expel less urine than normal, this is called
precipitancy.
 In LMN Lesion: At or below the anterior horn cells including the nuclei of CN.
i.
The bladder is hypotonic, it fills at a normal rate but the patient finds it difficult to
pass urine and must strain. The urine dribbles out due to lack of tone of the
detrusor muscle surrounding the bladder. This is called hesitancy.
8) Flaccid or Spastic muscles
 Differentiate between UMN and LMN lesion
A
B
C
13
Past History






Should be relevant to the system of the case
CVS Past History
 Pediatric case: Cyanotic spells and squatting. Squatting is due to relief of breathlessness
due to decrease in venous return when in that position.
 Adult case:
i.
Rheumatic Fever History (patient <55 years): When patient was young he/she
had repeated sore throat, along with migrating polyarthritis of bigger joints which
healed completely without residual pain.
ii.
Hypertension and IHD in patients >55 years
RS Past History - Pulmonary TB and BA
CNS Past History
 TIA history  TIA is complete recovery of a neurological deficit within 24 hours
 History of head injury
 Convulsion history
 CNS Infection and admission for the same
Per Abdomen Past History (Mostly liver)
 Jaundice within the past 3-5 years
 Blood transfusion within the past 3-5 years
 Repeated injections or IV drug abuse
 Hepatotoxic drug history
Generalized Past History
 Any significant major health problems
 Previous hospitalization
 Any major surgeries
Personal History




Diet and Appetite
 Vegetarian: tape worm infections, dietary deficiencies (fat soluble vitamins, protein)
 Mixed
 Appetite increased in DM and Hyperthyroidism
Sleep disturbance: normal or altered
Bowel and Bladder: mentioned above
Addictions: Smoking, Alcohol, drug use, tobacco and pan chewing
 What? How long? How much?
 Smoke and Pack Index
i.
Pack Year = (packs smoked per day) x (years as a smoker)
 To cause ALD: 80-120 grams of alcohol daily for males and 60-80 grams for females for 810 years
 Safe Drink: Males  24 units/week, Females  14 units/week
i.
Coronary protective: Increased HDL, Lowers LDL
 Menstrual history in females: menarche, LMP, cycles, menopause if relevant
14
Family History


Pedigree Chart
Married or Not
 Consanguineous marriage
Drug History




Diabetic Drugs
Antihypertensive Drugs: Increased urine – diuretic
Digoxin – Given only on weekdays
Rifampicin – orange colored urine, TB or leprosy patient
15
General Physical Examination
12 Points + 4 Points for Specific Systemic Examination
General Points
1. Age
2. Sex
3. Consciousness and Cooperativeness
4. Build
5. Pallor
6. Icterus
7. Lymphadenopathy
8. Cyanosis
9. Clubbing
10. Jugular Venous Pressure
11. Edema
12. Temperature
4) Build



Assessed by height in cm
Nourishment assessed by weight in kg
BMI = (weight in kg) / (height in m2)
5) Pallor


1.
2.
3.
4.
Systemic Points
Liver – Peripheral signs of Hepatocellular
failure
CVS – Peripheral signs of Infective
Endocarditis
CNS – Neurocutaneous markers
Female Patients (>35 Years) – Breast
examination
BMI Grading
Normal: 17-22 kg/m2
Overweight: 22-27 kg/m2
Obese: 27-32 kg/m2
Morbidly Obese: 32-37 kg/m2
High Mortality: >38 kg/m2
Assessed in the Palpebral conjunctiva,
tongue, nail bed
A pale palpebral conjunctiva means a hemoglobin of <7gm%
lips,
6) Icterus

Assessed in the Bulbar conjunctiva, floor of mouth, and nail bed
“Look up for Pallor, Look down for Icterus”
16
7) Lymphadenopathy


Groups of Lymph Nodes to Examine
Cervical
 Axilla
o Submental
o Apical
o Submandibular
o Anterior
o Preauricular
o Posterior
o Postauricular
o Media
o Jugulodigastric
o Lateral
o Anterior and Posterior Cervical
(Along the SCM)
o Scaleni
o Supraclavicular
Inguinal
 Other
o Superficial  can be ignored in
o Epitrochlear
rural farmers, due to chronic
o Abdominal – In thin individuals
infection from the foot
o Popliteal
o Deep
Virchow’s Node
Left Supraclavicular lymph node between the
two heads of SCM.
Positive lymphadenopathy in: CA of breast,
ovary, stomach, testes and pancreas




Significant Lymphadenopathy
1.
If more than one group is involved
2.
If a single group  1.5 to 2 cm in size
3.
Matted texture
4.
Tender to touch
5.
Fixed to skin or underlying structure
READ EXAMINATION OF LN FROM DAS
Epitrochlear Lymphadenopathy
o Examine by using the same hand as the patients arm, use the thumb to palpate above
the medial epicondyle.
o Enlargement is seen in: NHL, HIV, Sarcoidosis, Secondary Syphilis
Cervical Lymphadenopathy
o Acute Bilateral – Viral URTI or Streptococcal pharyngitis
o Acute Unilateral – Streptococcal or Staphylococcal infection
o Subacute or Chronic – Cat-scratch disease and Mycobacterial infection
Generalized Lymphadenopathy
o Viral Infection
o Malignancies
o Collagen Vascular Diseases
o Medications
17
8) Cyanosis
a. Definition: Bluish discoloration of the skin and mucous
membrane due to an increase in reduced hemoglobin of
more than 4-5 gm%
b. Types
i. Central – Defect at level of the heart or lung
ii. Peripheral – Saturation defect at tissue level
iii. Mixed – Seen in congestive cardiac failure
iv. Differential – Cyanosis in the Lower Limb but no in
the Upper limb
1. Seen in PDA with reversal of shunt due to
pulmonary hypertension
Central Cyanosis
 Defect at level of Heart and Lung
 Warm Extremities
 No change on warming hands
 Disappears on oxygen
Eisenmunger’s Syndrome
Refers to any untreated CCD with
intracardiac communication that leads
to pulmonary hypertension. LR
shunt is converted into a RL shunt.



Differential Cyanosis
Peripheral Cyanosis
 Defect at tissue level
 Cold extremities which disappear on
warming
 No change on oxygen
Assessed in:
Central: Lips and Tongue
Peripheral: Nail Bed, Tip of Nose and Ears
9) Clubbing
Bulbar enlargement of the nail bed
Theories of Clubbing
1) Hormonal Theory (PTH, GH, Estrogen)
2) Neurogenic Theory (Stimulation of Vagus)
3) Platelet Derived Factors (Stimulation of PDF)
4) Hypoxic Theory
5) Ferritin Theory (Ferritin deposition)
Grade of Clubbing
1) Softening of nail bed, with obliteration of
the nail bed angle (Lovibond angle)
2) Increased AP curvature of nail (parrot beak
appearance)
3) Grade 2 + Increased transverse curvature
(drum stick appearance)
4) Hypertrophic osteoarthropathy
a. Demonstration: Pressing the arm (along long bone) and joint, consequently the
patient complains of pain.
18
Causes of Clubbing
 GI Causes
o Liver Cirrhosis
o Chronic Diarrhea (IBD, Biliary
Cirrhosis)

10)
Respiratory System
o Bronchogenic Carcinoma
o Lung Abscess
o Bronchiectasis
o Empyema
o Mesothelioma

Severe Clubbing without Disease
o Congenital Clubbing

Unilateral Clubbing
o Hemiplegia
o Pancoasts Tumor

CVS
o Infective Endocarditis
o Cyanotic CHD

CNS
o Hemiplegia
o Tabes Dorsalis
o Syringomyalgia

Endocrine
o Acromegaly
o Hypo/Hyper-thyroidism

Unidigital Clubbing
o Trauma
o Gout
Jugular Venous Pressure
o Defined as the mean Right Atrial Pressure
o Normally not seen – as it lies behind the clavicle
o Measurement
 Patient should be in a lying down 45O position
 Turn the patient’s head to the left
 Place Two scales
 One perpendicular to the ground at the
Manubrio-Sternal Junction
 Second Parallel to the ground at the upper
most wave of the visible JVP
 Measure the JVP by reading the first scale in
centimeters
 Add 5 cm to the reading to adjust for the distance of the RA from the JVP wave
o At a 45O position the JVP is 0 cm column of blood
 In a supine position – the JVP may read as false positive
 In a standing position – the JVP may read as false negative
o Final report example: “JVP was found to be 11 cm of column of blood, measured from the
manubrio-sternal joint, where the JVP wave was seen along the left internal jugular vein.”
o Waves
 A wave – Indicates RA pressure
 V wave – Positive during early ventricular contraction due to bulging of the Tricuspid
 Y wave – Due to ventricular filling
 C wave – not seen
19
11)
Edema

12)
Vitals




13)
14)
15)
16)
Pitting edema is palpable one inch above the medial malleolus on the tibia
o Press for 15 seconds and assess for pitting
Temperature
Pulse – location, rate, rhythm, volume, character, and all peripheral pulses and
synchronicity
Respiratory Rate – AT, TA
Blood Pressure – location and position
In Liver – peripheral signs of hepatocellular failure
In CVS – Peripheral signs of infective endocarditis
In CNS – Neurocutaneous markers
In a Female >35 years – Breast examination
20
Pulse
Features of Pulse
1. Rate
Irregularly Irregular
 Atrial Fibrillation
Regularly Irregular
 Pulsus bigeminus – Two heartbeats
followed by a long pause
 Pulsus trigemini – Three heartbeats
followed by a long pause
a. Normal: 70-100 bpm
b. Tachycardia: >100 bpm
c. Bradycardia: <60 bpm
2. Rhythm  Regular or Irregular
Diagnosis of AF bedside  Demonstrate pulse
deficit
 Pulse Deficit
o Two Persons, one counting peripheral radial pulse, and the other counting Heart Rate
with stethoscope, simultaneously for One Minute.
o If the HR is 10 or more than the pulse rate it signifies a clinical diagnosis of AF, less
than 10 is simply due to premature contractions (extra systoles), equal is normal.
3. Volume
a. Pressure of volume felt on the pulp of the fingers on palpation
b. High volume pulse in Anemia (Hypervolume states)
c. Low volume pulse in Shock
4. Character
a. Water Hammer Pulse  High systole with low diastole
i. Wide pulse pressure – ex: 170/40 mmHg = PP of 130
ii. Conditions of WHP
1. Physiological – Pregnancy
2. Hyperdynamic circulatory states: hypoproteinemia, thyrotoxicosis, anemia
3. Atrial Regurgitation
4. L  R Shunts (ASD, VSD, PDA)
iii. To demonstrate for example on patient’s right arm…
1. Method 1: Use your left hand to palpate the pulse, lift quickly above the
heart, pulse will disappear and then reappear
2. Method 2: Use right hand to palpate pulse, use left hand to palpate along
arm, lift quickly above heart, you will feel pulse on left hand and back to
right.
b. Pulsus paravas – Low volume pulse, seen in mitral stenosis
c. Pulsus paravas et tardus – upon palpation, the pulse is weak/small (parvus) and late
(tardus) relative to its usually expected character, seen in aortic stenosis.
d. Pulsus alternans – alternating strong and weak beats, seen in Acute LVF
e. Pulsus paradoxsus – Exacerbation of normal physiological phenomenon
i. When during inspiration, systolic BP normally falls 7-8 mmHg
ii. If it falls more than 10 mmHg during inspiration, it is known as pulsus paradoxsus
iii. Seen in sever BA and Cardiac tamponade
f. Pulsus trigemini – seen in Digoxin toxicity
21
5. Synchronicity of Peripheral Pulses
a. To be
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
checked
Radio-Radial (Both Radial Arteres)
Brachial Arteries
Carotid – never simultaneously, causes vagal inhibition, carotid massage
indicated in sever ventricular tachycardia
Both Facial Arteries
Temporal Arteries
Femoral Arteries
Popliteal Arteries
Dorsalis Pedis Arteries
Posterior Tibal Arteries
Radio-Femoral Delay
Brachial-Femoral Delay – Important to check in Coarctation of Aorta
Respiratory Rate
 Check by placing hand on abdomen and count for one minute
 16-20 cpm is normal
o >20 – tachypnea
o <14 – bradyapnea
 Types of Respiration
o Abdomino-Thoracic
 Seen in males, since the abdominal muscles are stronger
 AT becomes TA in peritonitis and ascites
o Thoraco-Abdominal
 Seen in females
 TA becomes AT in pleural disease
Blood Pressure
 Systolic – 120-140 mmHg
 Diastolic – 80-90 mmHg
 Should be measures in sitting and supping position for Postural hypertension
o First supine BP, ask patient to stand up, wait three minutes and check
standing BP, a decrease by 10 mmHg signifies postural drop in BP
22
Liver Case: Peripheral Signs of Hepatocellular Failure
It is due to excessive estrogen, progesterone, and testosterone which is supposed to
be metabolized in the liver.
Head to Toe Signs Include
 Hepatic Facies – Shrunken eye,
 Loss of axillary hair
parched lip, hollow temporal fossa
 Clubbing
 Parotid Swelling
 Flapping Tremors
 Jaundice
 Dupuytren’s Contractures
 Fetor hepaticus – fishy odor
 Palmar Erythema
 Spider Naevi
 Leukonychia
 Gynecomastia in Males
 Loss of pubic hair
 Breast Atrophy in Females
 Testicular Atrophy
 Ascites
 Pedal Edema
Gynecomastia
 Definition: In males, the areola of the breast and nipple is more than 4-5 cm, and
it should be nodular and tender to palpation.
 Use palm of the hand and rotate on the areola for nodularity and tenderness
 Causes:
1. Testicular Tumors
2. Genetic – Hormonal
3. Drugs – Cimetidine and Digoxin
4. COPD, mostly in elderly
Testicular Atrophy
 Called atrophy when the size of the testicle is less than 2 cm
 Orchidometer is used to measure the size
23
CVS Case: Peripheral Signs of Infective Endocarditis
Peripheral Signs include
 Anemia
 Fever
 Clubbing
 Splinter Hemorrhages
 Palmar Erythema
 Asler’s Nodes
 Janeway Lesion






Roth’s Spots by ophthalmoscope
Change in murmurs
Carotid Bruit
Splenomegaly
Hematuria
Hemiplegia
CNS Case: Neurocutaneous Markers
 Café au lait spots
o Dark brown lesion >5 cm or more than 5 in one area
o Seen in NF type 1
 Trophic ulcers due to sensory loss
 MORE TO ADD in second round of classes
24
Abdominal System Examination
8+4+4+4 = 20 Points in Total
Inspection – 8 Points
1. Shape
2. Skin
3. Movements with Respiration
4. Umbilicus
5.
6.
7.
8.
Hernial Orifices
Veins
Visible Mass and Peristalsis
Scrotal Examination in Males
Palpation – 4 Points
1. Superficial  Muscles guarding and tenderness
2. Deep palpation for liver and spleen
3. Bimanual ballottement of kidney
4. Measurements
a.
b.
c.
d.
e.
Upper Half
Lower Half
Right Side
Left Side
Abdominal Girth
Extra Examinations
 Per Rectal examination in
both sexes
 Per Vaginal examination in
females
Percussion – 4 Points
To demonstrate free fluid in the peritoneum
1. Puddles Sign – paraumbilical percussion
2. Shifting Dullness
3. Horseshoe Dullness
4. Fluid Thrill
Auscultation – 4 Points
1. Peristaltic (Bowel) Sounds
2. Bruit
3. Venous Hums
4. Friction Sounds
Regions of Abdomen
1.
2.
3.
4.
5.
Right Hypochondrium
Epigastric
Left Hypochondrium
Right Lumbar
Umbilical
6.
7.
8.
9.
Left Lumbar
Right Iliac
Supra Pubic
Left Iliac
25
Inspection – 8 Points
1. Shape
 Normally Scaphoid
 Abnormal/Physiological  Distended (5 F’s: Fat, Feces Fetus, Flatus, Fluid)
 Uniformly distended abdomen is one in which the flanks are full
 Any fullness or mass should be mentioned
2. Skin
 Stretched or Shiny
 Increased folds – in dehydrated skin
 Scars, Striae (stretch marks), Tatoo marks, Moles, or any other abnormality
3. Movement with Respiration
 All quadrants should move equally with respiration
 Movements are reduced in abnormalities such as peritonitis, and hepatomegaly
4. Umbilicus
 Normally round, Inverted, and Central
 Transverse stretch in ascites – called a smiling umbilicus
5. Hernial Orifices
 Inguinal, Umbilical, or Incisional Hernias
6. Veins
 Visible Veins
 Patient should be examined in standing position
 Veins are visible around the umbilicus, flanks, epigastric and suprapubic area as
well as the back.
 Visible veins should be palpated by two finger technique.
7. Visible Mass and Peristalsis
 Visible peristalsis is seen in intestinal obstruction
 Watch for at least 5 minutes
8. Scrotal Examination in Males
 Examine for hydrocele, varicocele, as well as testicular atrophy
 Testicular atrophy is defined as testes <1.5-2 cm in size with loss of sensation
Palpation – 4 points
Ensure that the patient is in supine position with legs flexed, and warm your hands
before palpation.
1. Superficial Palpation
 Gently press all 9 regions of the Abdomen, watch for guarding or tenderness.
 Tenderness is examined by watched for a wincing reaction on the patient’s face
 Difference between Guarding and Rigidity
 Guarding is a voluntary action before the onset of pain as the patient knows that
the pain is imminent and is preparing by voluntarily contracting.
 Rigidity is involuntary – seen is Parkinson’s and Extrapyramidal lesions
26
2. Deep Palpation
Liver



Conventional Method (Supine Position, Legs Flexed)
 Palpate with your hand at a right angle to the MCL and ascend upwards until liver
palpable. Try to palpate in each inspiration.
 Normally the liver is not palpable, left lobe may be palpable in lean individuals.
Hooking Method (Supine Position, Legs Flexed)
 Stand on the right side of the patient, hook your left hand under the costal
margin. Upon inspiration the liver may be felt.
Dipping Method (Supine Position, Legs Flexed)
 Used in massive ascites
 Use both hands and press once to displace the fluid, and a second time to
attempt palpation of the liver.
 Hands are kept one on top of the other.
Points when Hepatomegaly is present
Points when Spleenomegaly is
 Extent of enlargement?
present
 Check liver span – Percuss upper and lower border along MCL,
cm)
 Normal
Grading(13-14
of Spleenomegaly
 Surface of the Liver
 Mild: 0-4 cm (2 finger
 Smooth – Fatty Liver
lengths)
 Irregular – Secondaries
 Moderate: 4-8 cm (4 finger
 Consistency
lengths)
 Soft – Fatty Liver, Hep
 Gross: >8 cm or crossing
 Firm – Early Cirrhosis
the umbilicus
 Hard – Secondaries
 Check liver span – Percuss
 Margins – Round or Sharp
upper and lower border along
 Tender or Non-Tender
MCL, Normal (13-14 cm)
 Tender – RHF, Hep, Amebic/Pyogenic Abscess, ITP
 Surface
 Pulsatile or Non-Pulsatile
 Consistency
 Pulsatile in Aortic and Tricuspid Regurgitation
 Margins – Round or Sharp
 Tender or Non-Tender
 Pulsatile or Non-Pulsatile
Spleen
 Pulsatile in Aortic
 Conventional Method (Supine Position, Legs
Regurgitation (Rosenburg
Flexed)
Sign)
 Palpate towards the spleen along the


spino-umbilical line, beginning from the
right iliac fossa
Right Lateral Method
 Fix spleen with the left hand, turn patient
to the right lateral position. The spleen will be felt on respiration
Hooking Method
27

 Stand on the left side of the patient. Use your right hand and hook under the
costal margin. Spleen will be felt.
Dipping Method
 Similar to dipping method in liver palpation. Used in massive ascites.
Causes of Gross Spleenomegaly
 M – Chronic Malaria
 M – Chronic Myeloid Leukemia
 M – Myeloproliferative Disorders
 M – Metabolic Conditions (Gaucher’s and Niemann Pick
Disease)
 K – Kala Azar




3.
Bimanual Kidney
Ballottement
Place the left hand on the
patients back and the right hand
anteriorly, push from below up to
feel the kidney with the right hand.
4.
Measurements
Upper Half
Lower Half
Right Side
Left Side
Abdominal Girth
 At level of lowest costal margin
o For obesity
 For ascites – at umbilicus
 Abdominal Girth more than 110 cm occur in central obesity, diabetes,
hypercholesterolemia, altered lipid profile, metabolic X syndrome
Percussion – 4 Points
Done to demonstrate free fluid in the Peritoneum
1. Puddle’s Sign (Aka: Paraumbilical, Knee-Elbow Percussion)
a. Put the patient in knee-elbow position
b. Percuss around the umbilicus – it is normally tympanic  if dull it indicates fluid in the
peritoneum (80-120 ml)
c. Auscultopercussion – place the diaphragm of the steth around the umbilicus, scratch
the skin by the steth, a flash of fluid is heard.
2. Shifting Dullness
a. Corresponds to more than one liter of fluid
b. Percuss from the xiphisternum to the bladder. If area around xiphisternum if dull then
stop  means massive ascites under tension
c. Percuss till dull laterally from the umbilicus  Move finger slightly more lateral and hold
d. Place the patient on their lateral side and wait 30 seconds for the organs to shift
upwards and fluid to shift downwards.
e. Percuss on the held position  should be tympanic, Percuss towards the umbilicus 
should be dull.
f. Repeat on the opposite side
28
3. Horseshoe Dullness
a. Seen in massive ascites (>3-4 L), but not under tension
b. Percuss from the Xiphisternum towards the umbilicus, mark where dull
c. Percuss towards 4 other directions and mark where dull
d. When the markings are connected it is horseshoe shaped
4. Fluid Thrill
a. Seen in massive ascites under tension
b. Place patient’s left hand on their stomach to prevent the thrill going through the skin and
underlying subcutaneous tissue.
c. Tap with your finger on the flank and feel for the thrill on the other flank.
Auscultation – 4 Points
1. Peristaltic Sounds
a. Keep diaphragm of the steth on any region of the abdomen for at least 5 minutes
b. A gurgling sound will be heard every 3-5 minutes
c. Increased – Diarrhea and Hunger
d. Decreased – Paralytic Ileus
2. Bruit
a. Listen for Renal artery bruit, One inch below and lateral from the umbilicus with the bell
of the stethoscope.
3. Venous Hum
a. Auscultated from xiphisternum to umbilicus with the diaphragm of the steth
b. Occurs in portal hypertension due to porto-caval anastomosis (Cruveilhier-Baumgarten
Syndrome)
4. Friction Sounds
a. Over the liver and spleen if enlarged due to peritonitis
Extra Examinations
Per Rectal Examination – in both sexes, check for hemorrhoids, CA rectum, and BPH in Males
Per Vaginal Examination – in women over 35 to check for CA cervix
29
Cardiovascular System Examination
3+3+3 = 9 Total Points
Patient should be examined in supine position, except auscultation of Aortic and
Pulmonary Area which should be examined in sitting position.
CVS Format
 Inspection (3)



1. Pre-Cordial Bulge
2. Site of Apex Beat
3. Other Pulsations
i. Epigastric
ii. Right 2nd Space Pulsation (Just Lateral to Sternum)
iii. Suprasternal Pulsation
iv. Left 2nd Space Pulsation (Just Lateral to Sternum)
Palpation (3)
1. Parasternal Heave
Location of Heart Sound
2. Apex Beat
Mitral (Apical) Area
Left 5/6th ICS, Half inch
i. Site
medial to the MCL
ii. Type
Tricuspid Area
Just Lateral to
Xiphisternum on the Left
iii. Thrill
Side
3. Palpable P2 (Diastolic Shock)
Aortic
Area
(A2)
Right 2nd ICS, Lateral to
Percussion (1) – Percussion of left
the Sternum
2nd space just lateral to sternum
Pulmonary Area (P2)
Left 2nd ICS, Lateral to
Auscultation (3)
the Sternum
1. Heart Sound
Erb’s Area (Point) –
Left 3rd ICS, Lateral to the
2. Murmur
Newer Aortic Area (P2)
Sternum
3. Additional Sound
Inspection – 3 Points
1. Pre-Cordial Bulge
o Examine tangentially at the foot end of the patient to compare both sides of the chest.
o A bulge indicates that the heart is enlarged before fusion of costal cartilage.
 Indicates a long standing cardiac problem
 Costal cartilage fuses
 Females – 15-17 years
 Males – 16-18 years
2. Apex Beat
o Site – Normally in the Left 5th/6th ICS, half an inch medial to the MCL
o Lateral to the Normal Site  Right Ventricular Hypertrophy
30
o Lateral and Inferior to Normal Site  Left Ventricular Hypertrophy
3. Other Pulsations
o Epigastric Pulsation
 Indicates Right Ventricular Hypertrophy
 Ask patient to hold breath in Expiration
o Right 2nd Space Pulsation (Aortic Area)
 Indicates Aneurysm of the Ascending Aorta
o Suprasternal Pulsation
 Indicates Aneurysm of Arch of Aorta
o Left 2nd Space Pulsation (Pulmonary Area)
 Indicates Pulmonary Artery dilatation due to Pulmonary hypertension
Palpation – 3 Points
1. Parasternal Heave
a. Keep Ulnar border of hand on the precordium
b. Indicates Right Ventricular Hypertrophy
c. Ask patient to hold breath in expiration
2. Apex Beat
a. Site
b. Type
i. Normal – Finger lifts, sustained less than 30% of diastolic beat
ii. Heaving (Concentric Hypertrophy) – Finger lifts, sustained more than 30%. Seen
in Systolic overload (Aortic stenosis, Hypertension)
iii. Forcible (Eccentric Hypertrophy) – Not sustainable, Hyperdynamic Apex, Seen in
Aortic and Mitral Regurgitation.
iv. Tapping – Finger not lifted at all, Palpable 1st Heart Sound, Seen in Mitral
stenosis
c. Thrill
i. Palpable murmur
ii. Correlate with carotid with Left hand to tell whether the murmur is systolic or
diastolic.
3. Palpable P2 – Diastolic Shock
a. Keep Ulnar border of hand at Pulmonary Area, feel for P2
b. Indicates Pulmonary Artery Dilatation due to Pulmonary Hypertension
Percussion – 1 Point



Left 2nd space, just lateral to the sternum
Normally Resonant
If dull  Indicates Pulmonary Artery dilatation due to Pulmonary Hypertension
31
Auscultation – 3 Points
1. Heart Sound
↑ - MS, TS
↓ - MR, TR
S2
Heart Sound
A2
↑ - Hyperdynamic Circulatory States (Anemia, Thyrotoxicosis, Beri-Beri)
↓ - AS, AR
S2
P2
↑ - Pulmonary Hypertention
↓ - PS, PR
2. Murmur
MS
MR
AS
AR
1. Site of Ausc.
Mitral Area
Mitral Area
Aortic Area
Aortic Area
2. Type of Murmur Diastolic
Systolic
Systolic
Di007Aastolic
3. Timing
Mid Diastolic
Pan-Systolic
Mid-Systolic
Early Diastolic
4. Character
Rough &
Blowing
CrescendoHarsh
Rumbling
Decrescendo
Decrescendo
5. Pitch
Low
High
Low
High
6. Radiation
None- Well
Left Axilla & Back Up along Carotid
Down Lateral
Localized
border of sternum
7. Position of Pt
Supine - Left Lateral Position
Sitting Leaning Forward
8. Bell/Diaphragm Bell – Diastolic
Diaphragm – AS is Systolic Low Pitch (LP)
LP
9. Phase of Resp. All Four Heard Better in Expiration – as A and M valves are on Left Side of
Heart
10. Grading
Grading of Murmurs – Only Systolic Murmurs, Diastolic Murmurs do not have Thrill
Grade 1
Faint Murmur – Heard in a silent room
Grade 2
Faint Murmur – Heard in a normal room
Grade 3
Loud Murmur – No Thrill present
Grade 4
Loud Murmur – Thrill Present
Grade 5
Loud Murmur with thrill and with diaphragm touching chest wall
Grade 6
Loud Murmur with thrill and without diaphragm touching the chest wall
3. Additional Sounds
a. Opening Snap – Mitral Stenosis
b. Ejection Click – AS
c. Pericardial Rub - Pericarditis
32
Respiratory System Examination
4(1)+4(2)+4(3)+4(4)+4(5)=20
1. Examination of Upper Respiratory System (Above Cricoid)
1.
2.
3.
4.
Nose
Para Nasal Sinuses
Throat
Ears
 Examination of Lower Respiratory System (Below Cricoid)
1. Inspection
 Position of Mediastinum – Trachea and Apex Beat
 Shape of Chest
 Movements of Chest with Respiration
 Drooping of Shoulder
2. Palpation
 Position of Mediastinum
 Measurements
 A/P
 Transverse
 Chest Expansion – Deep Inspiration / Deep Expiration
 Hemi Thorax Expansion
 Tactile Vocal Fremitus
 Movements of Chest
3. Percussion
 Direct Percussion of Clavicle
 Percussion of Lung Fields
 Cardiac Dullness
 Upper Border of Liver Dullness
4. Auscultation
 Air Entry
 Type of Breath Sounds
 Additional Sounds
 Vocal Resonance
Areas of RS Examination


Anteriorly
o Supraclavicular
o Infraclavicular
o Mammary
Posteriorly
o Suprascapular
o Interscapular

Axillary – Areas separated by 4th rib
o Axillary
o Infra-Axillary
33
o Infrascapular
Upper Respiratory System Examination
1. Nose – Normal
2. Para Nasal Sinuses
 Tenderness –
 Front – Press Medial Part of Roof of Orbital Ridge
 Ethmoidal – Between the eyes
 Maxillary – Roof of mouth just behind the canine
3. Throat – Examine with Tongue depressor and a Flashlight
4. Ear – Examine for discharge
Lower Respiratory System Examination
1. Inspection
 Position of Mediastinum
 Trachea should be central – Slightly right may be normal
 Apical Beat – Half inch medial to MCL in Left 5th ICS
 Shape of the Chest
Pleural Effusion – Push of MS
 Normal – Elliptical, Pyramid (From Lateral
Collapse – Pull of MS
View)
Consolidation – MS will be Central
 Anteriorly
 Bulge – Pleural Effusion or Tumor
 Flat or Retracted – Fibrosis
 A/P - Narrow, Transverse Wide
 Movement of Chest with Respiration
 Anterior – Examine with the patient supine, Go to foot end of the bed
 Supraclavicular – Stand behind the patient, look at the shoulder tangentially
 Back – Stand in front of the patient, look at the should and back tangentially
 Drooping of the Shoulder – Due to Clavicle Fracture, Shoulder Dislocation,
Fibrosis and Collapse
 Examiners eyes should be at the level of the shoulders of the patient
 See from the Front and Back
2. Palpation
 Position of Mediastinum
 Left hand fixes the patients head, slightly flex.
 Right hand – Index and ring finger at the sternoclavicular joint, middle finger used
to insinuate at the root of the next, between the SCM and Trachea.
 Apical Beat – Palpate – Half inch Medial to Left MCL at 5th ICS
 Measurement
 Use two books, Measure AP and Transverse Diameter – Normally 5:7 Ratio
 Emphysema – AP = Transverse Diameter
 Chest Expansion – Normally 4-6 cm
34

Measure by placing a mark at the 4th ICS at the sternum, and the 2nd mark
at the level of T8 a point midway from Infrascapular angle
 Hemithorax – Measure at the same points
 Increased in Pleural Effusion and Pneumothorax
 Decreased in Collapse, Consolidation, and Fibrosis
 Spinoscapular Distance
 Measure from the Medial most part of the spine of scapula to the Lateral
part of the T4 Vertebrae. Normally both sides equal. Abnormal in Scoliosis
 Movements with Respiration
 Types of Breathing
 Bucket Handle and Hand Pump
 Areas that are Hand Pump – Supraclavicular, Suprascapular,
Infraclavicular
 Hand Pump areas examined with hands flat or fingers in the
Supraclavicular fossa
 Tactile Vocal Fremitus
 Vibration produced at the vocal cord transmitted through the trachea and bronchi,
which can be palpated with ulnar border of hand on the chest wall.
 It will be increased in consolidation and cavity formation
 Reduced or Absent in other conditions – Fibrosis, collapse, emphysema,
pneumothorax, and effusion
 Whenever there is Bronchial Breathing Vocal Fremitus and Vocal Resonance is
always increased.
3. Percussion
 Position
 Anterior Areas – Hands of Patient on Waist
 Axillary Areas – Hands of the Patient on the Head
 Posterior Areas – Hands on opposite Shoulders
 Notes
 Normal – Resonant
 Hyperresonant – Emphysema and Pneumothorax
 Impaired/Dull – Fibrosis
 Dull – Difference in Woody and Stony  Pleximeter pains on stony
 Woody – Consolidation
 Stony – Pleural Effusion
 Clavicle Percussion
 Pull skin down to fix the clavicle
 Percuss clavicle directly without pleximeter
 Percussion of All ICS in All Lung Fields
 Cardiac Dullness (Left 3rd, 4th, and 5th ICS) - Resonant in Emphysema
35
 Upper Border of Liver – Percussed at Right MCL
 Right 5th ICS at MCL
 Right 7th ICS at Mid-Axillary Line
 Right 9th ICS at Inferior Angle of Scapula
Upper Border of Liver:
Pushed Down in
Emphysema
Pulled Up in Fibrosis
4. Auscultation
 Air entry should be good
 Reduced in Fibrosis, Pleural Effusion and Collapse
 Types of Respiration
 Normal is Vesicular
 Abnormal is Bronchial
 Cavernous – Low Pitch (Seen in Cavitation, Thick walled cavity [TB])
 Tubular – High Pitch (Consolidation)
 Amphoric – High Pitched Metallic (Thin wall communicating cavity)
 Bronchovesicular – Prolonged expiration in case of emphysema
 Additional Sounds
 Crepitations
 Fine – Fibrosis, Early Pulmonary Edema
 Coarse – Chronic Bronchitis
 Leathery – Bronchiectasis
 Rhonchi (Wheeze-Symptom)
 Inspiratory or Expiratory, Monophonic or Polyphonic
 Bronchial Asthma – Expiratory Polyphonic (Many Bronchi Involved)
 Foreign Body – Monophonic (Single Bronchus Involved)
 Pleural Rub – Pleurisy
 Vocal Resonance
 Ask the Patient to Say One or Ninety-Ninety and auscultate in all lung
fields.
36
CNS Examination
1. Examination of Higher Mental Function
 Level of Consciousness
 Orientation to Time, Place and Person
 Hallucinations and Delusions
 Mood of the Patients
 Memory – Past, Present and Recent
 Speech
 Right or Left Handed
2. Examination of Cranial Nerves
 I – Test of Smell
 II – Acuity of Vision (Finger Count, Finger Movement, PL, PR)
Field of Vision
Color Vision
Light Reflex – Direct and Indirect
 III, IV, VI – Ptosis, Position of Eyeball, Movement of Eyeball, Accommodation
 V – Sensory Part (Ophthalmic, Maxillary, Mandibular Areas)
Motor Part – Muscles of Mastication (Masseter, Temporalis, Pterygoids)
Jaw Jerk
 VII – Sensory Part (Test for Anterior 2/3rds of Tongue)
Motor Part – Muscles of Facial Expression (Frontal belly of occiptofrontalis, orbicularis
oculi, levator angularis, buccinator, orbicularis oris, platysma
 VIII – Watch Test, Rinne’s Test, Weber’s Test
 IX, X – Position of Uvula, Pharyngeal Reflex, Gag Reflex
 XI – Sternocleidomastoid and Trapezius
 XII – Tongue in the Floor of the Mouth (Size, Fasciculation, Chorea)
3. Examination of Motor System
 Nutrition – Muscle Bulk at Arm, Forearm, Thigh and Calf
 Tone – To be tested by examining the group of muscles acting on the joint
 Power – To be tested by examining the group of muscles acting on the joint
 Coordination – Finger Nose Test, Heel-Shin Test
 Abnormal Movements
 Gait
 Reflex
 Superficial Reflex – Cornea, Abdominal, Cremasteric, Plantar
 Deep Reflex – Biceps, Suppinator, Triceps, Knee, Ankle
 Visceral and Primitive Reflex
37
4. Examination of Sensory System
5.
6.
7.
8.
 Touch

Tactile Localization
 Temperature

Two Point Discrimination
 Pain

Stereognosis
 Vibration

Graphasthesia
 Joint Position
Signs of Meningeal Irritation
 Neck Rigidity
 Kernig’s Sign
 Brudzenski’s Neck and Leg Sign
Examination of Cerebellar Function Test
 Titubation – Nodding movement of the head
 Nystagmus
 Dysarthria – Difficult or unclear articulation of speech
 Dysmetria –Lack of coordination of movement
 Past Point –
 Dysdiadokinesia
 Finger-Nose Test, Finger-Nose-Finger Test
 Rebound Phenomenon
 Heel Shin Test
 Cerebellar Gait
Examination of Skull and Spine
Examination of Cerebrovascular System
 Carotid Bruit
 Irregular Pulse
 Murmur
1 - Examination of Higher Mental Functions





Level of Consciousness
 Give a Verbal command
 Give a Superficial painful stimulus
 Give a Deep painful stimulus
Orientation to Time, Place and Person
Hallucinations and Delusions
 Hallucinations – False sensory perception without stimuli (visual, auditory, olfactory)
 Delusions – False sensory perception even in the presence of contrary
Mood of the Patient
 Normal, Depressed, Irritable, Ferocious, Angry
Memory
 Past Memory – Tested by asking a question which is relevant to at least One-year back
 Present Memory – A memory earlier that day
38



Recent Memory
 Give and object  Take it back  Ask what it was sometime later
 Tell the patient a number  ask 30 seconds later what number it was
Speech – Definition: Articulation of communication
 Two parts – Central or Peripheral
 Central – Aphasia (Tested by giving verbal and visual command)
 Peripheral – Dysarthria
 Broca’s Area  Expression Lost, Wernicke’s Area  Comprehension Lost
Right or Left Handed
 Right Handed Individuals – 100% are Left Dominant
 Left Handed Individuals – 85% are Left Dominant
 If Right side paralysis  Left Brain affected  Loss of Speech
2 - Examination of Cranial Nerves
I – Olfactory
Steps to examine smell
1. Close the eyes and one nostril of the
patient
2. Test the Patency of the nostril to be tested
3. Ask the patient to smell the substance
4. Ask the patient to tell what substance it
was
II – Optic
Visual Acuity
1. Snellen’s Chart
2. Finger Counting/Movement
3. PL/PR
Field of Vision
1. Finger Confrontation Test, Assumes
Examiner’s Field of vision is normal
Perimetry Preferred
 Patient’s and Examiner’s eyes
should be at the same level
 Ask the Patient to close the eye on
the same side of the examiners (RL, L-R)
 Examiner should bring their finger
inwards from the periphery
 Patient should tell the examiner when they see the examiner’s finger
 The examiner should judge whether the finger is seen at the same time or later
39
Color Vision Test
 Ischihara’s Color Vision Chart
 Colored Thread or Marbles
Light Reflex
 Direct Light Reflex tests the 2nd
and 3rd CN nucleus on the
same side, and the 3rd CN on
the opposite side.
 Indirect Light Reflex tests the
3rd CN nucleus on the same
side
III, IV, VI – Occulomotor, Trochlear, Abducens
 Ptosis – Upper 1/3rd of corneo-scleral junction covered
by the eyelid
 Position of the eyeball
o Lateral Rectus – Medial Rectus
o Medial Squint – Lateral Rectus
 Movement of Eyeball
o Tested simultaneously or Individually in an Hshaped pattern
 Accommodation – Adjust of optic apparatus by converging and constriction of pupil for near
vision, and dilation and divergence for far vision
V – Trigeminal
 Sensory Part – Test Touch, Temperature, and Pain
o Ophthalmic(a), Maxillary(b), Mandibular(c)
 Motor Part
o Muscles of Mastication
 Masseter – By clenching
 Temporal – By clenching
 Lateral Pterygoid – Ask patient to move jaw
laterally against resistance
 Medial Pterygoid – Open mouth, Cannot
exam individually
*Tongue and Jaw goes to the same side of the lesion
 Jaw Jerk
 Afferent and Efferent is the Trigeminal Nerve
 Normally present but not obvious
 If exaggerated  Lesion is Bilateral above the pons
 Example: Pseudobulbar Palsy (Primary Motor System Disease)
40
VII – Facial
 Sensory Part – Test of Taste (Anterior 2/3rd of Tongue)
o Patient should not talk throughout the test
o Make solution of three substances, Patient does not know the substances
o Protrude the tongue and dry with cotton
o Place a drop of solution on the lateral part of the tip of tongue
o Ask the patient to point at the solution used
o Wipe it, take a different solution and test the opposite side
 Motor Part – Muscles of Facial Expression
o Frontal Belly of Occipitofrontalis – Look up, forehead wrinkles (Frowning)
o Orbicularis Oculil – Ask the patient to close their eyes, try to open physically
o Levator Angularis – Check for naso-labial fold
o Orbicularis Oris – Whistling, puckering, and blowing action of the mouth
o Buccinator – Blow against a closed mouth
o Platysma – Clench teeth, look at the patient neck
VIII – Vestibulocochlear
 Watch Test
 Weber’s Test
 Rinne’s Test
IX, X – Glossopharyngeal, Vagus
 Gag Reflex, do if palatal reflex is absent, if uvula constricts palate goes up and motor is
intact
 Instruments – swab, tongue depressor, torch
o Depress the tongue, check position of the uvula
o Touch palate with swab – contraction (palate goes upward)
o Touch the posterior pharyngeal wall – pharynx comes forward
XI – Spinal Accessory Nerve
 Sternocleidomastoid – Push chin, ask patient to push against resistance
 Trapezius – Ask patient to shrug against resistance
XII – Hypoglossal
 Examined with tongue on the floor of the mouth
 Examine the size of the tongue
o Macroglossia – LMN Tongue, Flaccid
o Microglossia – UMN Tongue, Spastic
 Fasciculation
 Chorea – Explained as a ‘bag of worms’ in the mouth
 Protrusion of the Tongue – check the position
 Movement of the Tongue – Side to side
 Power – checked by pushing tongue against cheek
*Power of Tongue and Small muscles of hand cannot be graded
41
3 - Examination of Motor System
1. Nutrition
 Muscle Bulk – Measurement is from a fixed bony prominence, because the tape should not
cross the joint where there is max muscle bulk
 Arm – Lateral Epicondyle
 Forearm – Olecranon Process
 Thigh – Either Condyle
 Calf – Tibial Tuberosity
2. Tone – Resistance offered by the muscle during passive movement
Tested on the group of muscles acting on the joint of concern
 Hypotonia – LMN Lesions
 Normal Tone
 Hypertonia – UMN Lesions
 Clasp Knife Spasticity – Pyramidal Lesion
 Rigidity – Extrapyramidal Lesion (Agonist and Antagonist both Hypertonic)
1. Cogwheel – Rigidity + Tremors
2. Lead Pipe – Rigidity without Tremors
3. Power – Active movement against resistance
Tested on the group of muscles acting on the joint of concern
1. Grading
1 – Flickering
2 – Eliminating Gravity
3 – Against Gravity
4 – Mild Examiners Resistance
5 – Normal
Muscles that Act on each Joint
Shoulder
F – Pectoralis Major
E – Infraspinatus
Abduction
0-30o – Supraspinatus
30-90o – Deltoid
>90o – Trapezius
Elbow
F – Biceps
E – Triceps
Wrist
F – Long Flexors
E – Long
Extensors
Hip
F – Iliopsoas
E – Gluteus Maximus
Ab – Gluteus Minimus
and Medius
Ad – Adductor
Longus, Gracilis,
Gluteus Maximus
Knee
F – Hamstrings
E – Quadriceps
Ankle
F – Anterior Tibialis
E – Gastrocnemius
and Soleus
Ad – Latissimus Dorsi
4. Coordination
 Finger-Nose Test – Tested with eyes closed
 Finger-Nose-Finger Test – Tested with eyes open
 Heel-Shin Test
42
5. Abnormal Movements
 Tremors
 Chorea – movement disorder of peripheral joints, dancing like
 Hemiballismus – movement disorder of proximal joints
 Tonic Clonic
 Twitching
 Fasciculation
6. Gait
 Hemiplegic Gait (Seizure Gait)
 Short Shuffling Gait (Parkinson’s) – patient’s arms to their sides, small steps
 High Stepping Gait – Foot Drop seen, Patient is seen to take high steps
 Stamping Gait – Foot drop with pyramidal involvement
 Waddling Gait – Proximal muscle weakness, in pregnancy, hip fracture, myopathies,
dislocation
 Hysterical Gait – Haphazard
 Ataxic Gait – Falls to same side
7. Reflexes
 Superficial Reflexes
 Corneal – 5th CN (Afferent), 7th CN (Efferent)
 Abdominal – T7-T10 (Upper Abdomen), T10-T12 (Lower Abdomen)
 Scratch in a diamond shape away from the umbilicus
 Cremasteric (L1)
 Scratch the medial aspect of the Thigh (L1)
 Plantar Reflex (L5-L10)
 Blunt object used to scratch along the lateral aspect of the sole of the foot,
and then against the base of the toes up till the 3rd toe
 Pyramidal Lesion will show Babinski’s Sign
 Babinski’s Sign 5 Components
1. Up going Great Toe
2. Fanning of Other Toes
3. Dorsiflexion at the ankle joint
4. Flexion of knee and hip
5. Lateral rotation of hip due to contracture of tensor fascia lata
 Minimal Babinski’s – Only the Tensor Fascia Lata contracts – Lateral
Flexion
 Deep Reflexes – Motor response to a sensory stimulus
 Biceps: C5-C6
 Supinator: C5-C6
 Triceps: C6-C7
 Knee: L2-L3
 Ankle: L5-S1
Clonus – Indicates UMN, Patellar and Plantar both tested
43
4 - Examination of Sensory System
5 Points to be kept in mind
1. All tests should be done with eyes closed
2. Explain to the patient about the test in detail
3. Every segment C2 (Behind the Ear) to S5 (Perineal Area)
4. Compare sensation of Upper ½ and lower ½
5. Compare sensation of Right and Left side
*Touch, Temperature and Pain are Primary modalities of sensation










Touch
o Superficial (Cotton)
o Deep (Pen or Blunt Object)
Temperature – Cannot be tested accurately bedside
o Use two tubes with water 5o more and 5o less than room
temperature
Pain
o Sharp Object (End of a Knee Hammer)
Vibration Test
o Tuning Fork of 128 Hz or bony prominence (Condyles,
Spine, Ribes, etc.)
Joint Sensation
o Fix the joint to be tested, Thumb and Greater Toe to be checked
o Move the joint side to side, flex and extend
o Ask the patient which direction it was moved
o Mistake more than 3 times is significant
Position Sensation
o Examiner puts a joint in a certain position
o Patient should mimic the position in the other limb
Tactile Localization
o Examiner touches a certain point
o Patient should touch the same point with their finger
Two Point Discrimination
o Assessed with Calipers
Stereognosis
o An object in the patient’s hands should be guessed by the physical characteristics felt
by the patient
Graphesthesia
o On the back or thigh, the examiner should draw a number or letter, ask the patient to
guess what was drawn
44
5 – Signs of Meningeal Irritation
1. Neck Rigidity
 Examined in Supine Position
 Ask patient to flex their neck and bring their chin to chest
 Patient will complain of pain in the nape of their neck
 Patient more than 50 years old – Examine rigidity by moving neck side to side to rule
out cervical spondylosis
2. Kernig’s Sign
 Examined in Supine Position
 Flex one leg at the hip, extend the knee of the same joint
 Patient complains of pain in the hamstring due to
3. Brudzinski’s Sign
 Neck Sign – Flex Neck, patient will reflexively flex both legs at the hip
 Leg Sign – Flex the leg at the hip, patients opposite leg will also flex
6 – Examination of Cerebellar Function
Examine – Equilibrium, Coordination and Tone
 Titubation – Nodding of the head, unable to keep head straight
 Eye – Horizontal Nystagmus, Vertical  Brainstem Lesion
 Dysarthria – Staccato or Broken Speech, Ask the patient to say “British Constituency”
 Dysmetria
o Draw two lines, ask the patient to start at one line and end at the other, passing the 2 nd
line may be due to hypotonia.
o Draw a circle, ask the patient to place dots within the circle
 Dysdiadokinesia – Repeated movements of hands on palms
 Finger-Nose-Finger Test




Rebound Phenomenon
o Two arms outstretched – give a tap on each arm  hypotonia makes arms drop
Pendular Knee Jerk
o Sit the patient against a bed, knees should be parallel
o On knee reflex, the lower leg oscillates more than 3 times with the same intensity
Heel-Shin Test
Cerebellar Gait – Cannot walk in a straight line (Heel-Toe)
45
7 – Examination of Skull and Spine


For Tumors of Fracture of the Skull
Deformity or Tenderness of the Spine – Scoliosis, Kyphoscoliosis
8 – CVS Examination
1. Carotid for Bruit
2. Heart for Murmurs
3. Pulse for irregularities – Especially for Irregularly Irregular Pulse of Atrial Fibrillation
46
Abdominal System Viva Examination Questions
1. Causes of Uniform Distension of Abdomen
a. Fetus
b. Flatus
c. Feces
d. Fat
e. Fluid
f. Functional IBS
2. Differentiate between Obesity and Ascites
a. Obesity
i. Umbilicus inverted
ii. No Fluid Thrill
iii. Lower Half of Abdomen > Upper Half
iv. Centrally Distended Abdomen
b. Ascites
i. Umbilicus Protruded
ii. Fluid Thrill – If flanks are full
iii. Upper Half > Lower Half
iv. Uniformly Distended Abdomen includes Flank Fullness
3. Normal Liver Span and Importance
a. 13-14 cm in lenth
b. Percuss along MCL to examine length
c. Helps to determine hepatomegaly or pushed liver
4. Causes for Tender Hepatomegaly
a. Right Heart Failure
b. Hepatitis
c. Amebic Abscess
d. Pyogenic Liver Abscess
e. Budd-Chiari Syndrome
f. Hepatoma
5. Causes for Pulsatile Liver
a. Aortic Regurgitation
b. Tricuspid Regurgitation
c. Hemangioma of Liver
47
6. Causes for Splenomegaly
Mild – 2 finger below costal
margin or 0-4 cm
Acute Malaria
Acute Kala-Azar
Enteric Fever
Moderate – 2 to 5 fingers or 4-8
cm
Chronic Malaria
Chronic Kala-Azar
Portal Hypertension
Acute Viral Hepatitis
Lymphoma
Gross Splenomegaly – >8cm
M – Chronic Malaria
M – Chronic Myeloid Leukemia
M – Myeloproliferative
Disorders
M – Metabolic (Gaucher’s,
Nieman Pick)
K – Kala-Azar
Endocarditis
Chronic Lymphoid Leukemia
Miliary TB
Amyloidosis
Acute Leukemias
Sarcoidosis
Others:
ITP
Thalassemia, Polycythemia
7. Differentiate between Spleen and Left Kidney
Spleen
Kidney
Fingers cannot be inserted below costal margin
Can be inserted below costal margin
Moves freely with Respiration
Fixed to Posterior Abdominal Wall
Enlarges toward Right Iliac Fossa
Enlarges downward
Spleenic Notch can be felt
Not Notch felt
Spleen is Dull on Percussion
Kidney is Tympanic on Percussion
Spleen palpated with patient supine
Kidney is best palpated by bimanual
ballottement
8. Methods of Palpation of Spleen and Kidney
a. Spleen palpation done in supine position
b. Conventional
c. Dipping
d. Hooking Method – in Right Lateral Position
e. Kidney palpation done by bimanual ballottement of each lumbar area
9. Percussion of Spleen – Not Accurate
a. Nixon’s Method
i. Patient in Right Lateral position
ii. Percuss from Posterior Axillary Line along the costal margin
iii. If dullness is >8cm above costal margin in deep inspiration signifies enlargement
b. Castell’s Method
i. Patient in Supine Position
ii. Percuss along Anterior Axillary Line, where it joins the costal margin, it should be
tympanic in deep inspiration signifying Traube’s Space, If dull splenic
enlargement may be present
48
10. Traube’s Space
a. Definition: A triangular or semilunar topographic area in the lower left chest, bounded
laterally by mid axillary line, above by left dome of diaphragm, below by left lower costal
margin
b. Detected by percussion in supine position from xiphisternum to left mid axillary line
along the 6th and 7th Intercostal spaces (Barkun’s Method)
c. Normally tympanic as it contains the fundus of the stomach, tympanicity is lost in:
i. CA Stomach
ii. Left sided Pleural Effusion
iii. Enlarged Left Lobe of Liver
iv. Massively Enlarged Spleen
v. Situs Inversus
vi. Achalasia Cardia – Gas of stomach is absent
vii. Space is shifted up in fibrosis and collapse of upper left lobe of lung and left side
palsy of diaphragm
11. Cruveilhier–Baumgarten Sign
a. Venous hum heard between xiphisternum and umbilicus due to portal hypertension from
anastomosis of gastric vein to umbilical vein
12. Precipitating causes for Hepatic Encephalopathy
a. High Protein Diet
b. GI Bleed
c. Uremia
d. Constipation
e. Electrolyte Imbalance – Hypokalemia, Alkalosis, Hypoxia, Hypovolemia
f. Drugs – Furosemide, Tranquilizers, Sedatives
g. Infections
h. Major Surgery
i. Alcohol
j. Paracentesis
49
13. Causes and Complications of Cirrhosis of Liver
a. Causes
i. Viral Hepatitis (Hep B and C)
ii. Alcohol
iii. Metabolic (Wilson’s and Hemochromatosis)
iv. Cholecystitis
v. Budd-Chiari Syndrome
vi. Toxins
vii. Drugs
viii. Radiation
ix. Triscuspid Regurgitation – Cardiac Cirrhosis
x. Idiopathic
b. Complications
i. Portal Hypertension
ii. Ascites
iii. Hepatic Encephalopathy
iv. Spontaneous Bacterial Peritonitis
v. Hepatorenal and Hepatopulmonary Syndrome
vi. Hepatocellular Carcinoma
14. Mechanism of Ascites in Cirrhosis
a. Hypoproteinemia
b. Increased ADH due to inactivity
c. Overflow Theory  Fluid flows into the peritoneum  Kidney senses loss of fluid 
stimulates Renin-Angiotensin  Sodium and Water Retention
d. Underfilling Theory  Due to portal hypertension  Portal vein is constricted  No
secretion  Intravenous pressure drops  Stimulates Renin-Angiotensin  Sodium
and Water Retention
15. Mechanism of Clubbing in Liver Disease
a. Increased estrogen  Vasodilation in Pulmonary venous level  Causes hypoxia 
AV Shunts produced  increased proliferation of nail bed
16. What is Chronic Hepatitis? Either of the Following
a. If lab abnormalities are present for more than 6 months
b. Clinical Features are present for more than 6 months
c. Histopathological changes continue for 6 months
17. Types of Chronic Hepatitis
a. Autoimmune Type
b. Chronic Hepatitis due to Post-Infection of Hep B or C
c. Chronic and Active Hepatitis Infection
d. Chronic Persistence of Hepatitis
50
18. Uses of Lactulose
a. Acts like an osmotic purgative
b. Changes the pH of intestines so that ammonia production of bacteria falls
c. Prevents absorption of ammonia
d. Prevents production of nitrogen
19. Alcoholic Liver Diseases
a. Fatty Liver
b. Hepatitis
c. Cirrhosis of Liver – Hepatocellular carcinoma
20. Abdominal Growth Measurement and its importance
a. Measure obesity at costal margin
b. Measure ascites at umbilicus
c. Helps for prognosis of the patient
21. Differentiate between mid-line mass and ascites
a. Midline Mass – Lower Abdomen > Upper Abdomen, Ascites is opposite
b. In Midline mass – the flanks stay tympanic
c. Convexity of dullness is facing up in mid line mass, and it is horseshoe type in ascites
22. Causes of Portal Hypertension
a. Pre-Hepatic
b. Hepatic
i. Pre-Sinusoidal
ii. Sinusoidal
iii. Post-Sinusoidal
c. Post-Hepatic
i. Budd-Chiari Syndrome
ii. Clot
iii. Stricture
iv. CA Head of Pancreas
23. What is Fulminant Hepatitis?
a. Within 3-4 weeks after acute hepatitis, there is extensive destruction of hepatocytes with
coma and death, without pre-existing liver disease
24. Differences between Hepatitis A, B, C, D, and E
25. Hypersplenism
a. Splenic hyper activity with destruction of RBCs
b. Diagnostic criteria are
i. Splenomegaly
ii. Pancytopenia
iii. Normal or Hypercellular Bone Marrow
iv. Reversible with splenectomy
26. Tropical Splenomegaly
a. Seen in Plasmodium falciparum with massive splenomegaly without proportionate
antibodies to parasites, Antibodies > Parasites
51
27. Causes of Acute and Chronic parenchymal liver disease
a. Acute – Viral, Drugs, Toxins, Radiation, Metabolic
b. Chronic – Wilson’s and HCC
28. Causes for Rigidity of Abdomen
a. Intestinal Perforation
b. Acute Pancreatitis
c. Cholecystitis
d. Salphingitis
e. Peritonitis
f. Intersucception
g. Superior Mesentery Artery Thrombosis
h. Ruptured Ectopic Pregnancy
i. Twisted Ovarian Cyst
j. Fibroid Torsion
29. What is Thumping Sign?
a. Strike right lower rib cage with the first, if tenderness it indicates liver pathology and
enlargement because liver hits the posterior wall
30. Murphy’s Punch
a. Method of eliciting loin tenderness for Kidney
b. Punch posterior lumbar area for kidney pathology
31. Hepatic Facies
a. Shrunken Temporal Fossa
b. Shrunken Eyes
c. Malar Prominence
d. Parched Lips
e. Muddy Skin
f. Jaundice of Conjunctiva
g. Dry Face
32. Troisier Sign
a. Positive presence of a hard and enlarged Virchow’s node in Left supraclavicular area
33. Stigmata of Alcoholic Liver Disease
a. Bilateral Parotid Swelling
b. Dupytryne’s Contractures
c. Gynacomastia
d. Testicular Atrophy
34. Causes of Pain Abdomen in Cirrhosis
a. Gastritis
b. Cholecystitis
c. Pancreatitis
d. Intestinal Perforation
e. Spontaneous Bacterial Peritonitis
52
35. Caput Medusa
a. Dilated tortuous veins going away from the umbilicus
b. Seen in Portal Hypertension
36. Gynecomastia
a. In males the areola of breast nipple is more than 4-5 cm, nodular and tender on
palpation with palm
b. Causes
i. Testicular Tumor
ii. Drugs – Cimetidine, Digoxin, Spironolactone
iii. Puberty
iv. Liver Diseases – Cirrhosis
v. Estrogen Hormonal Therapy
37. Flapping Tremors
a. Definition – Inability to maintain the posture of an extended arm and wrist
b. Mechanism – In liver disease, all un-metabolized end products crosses the BBB and
acts as false neurotransmitters at the ascending and descending reticular activating
system
c. Seen in – Coma, CRF, Liver Failure, Lung Failure
38. Differences between IVC Obstruction and Portal Vein Obstruction
a. Portal Hypertension – Flow away from the Umbilicus
b. IVC – Towards the Umbilicus
39. Causes for Tender Splenomegaly
a. Enteric Fever
b. Infective Endocarditis
c. Rupture or Infarct of Spleen
40. Dupytryne’s Contracture
a. Mechanism not known
b. Assumed to be due to free radicals damaging the connective tissue of palmar fascia
41. Grading of Enlargement of Liver
a. Mild – 1-2 finger breadth from right lower costal margin in MCL
b. Intermediate – 2-4 finger breadths
c. Massive - >4 finger breadths
42. Fluid Thrill causes other than ascites
a. Large Hydatid Cyst
b. Ovarian Cyst
53
43. Causes of Spider Naevi
a. Cirrhosis
b. Pregnancy
c. Alcoholic Hepatitis
d. Thyrotoxicosis
e. RA
f. Estrogen Therapy
44. Light’s Criteria
a. Helps to differentiate between transudate and exudates
b. Pleural Protein to Serum Protein Ratio - >0.5 in exudate, <0.5 in transudate
c. Pleural Fluid LDH to Serum Fluid LDH - >0.6 in exudate, <0.6 in exudate
45. SAA Gradient
a. Albumin difference between serum and asitic fluid
i. >1.1 gm/dl – transudates
ii. <1.1 gm/dl – exudates
46. Gross Hepatomegaly
a. >10 cm from costal margin at MCL
54
Respiratory System Viva Examination Questions
1. Causes for Push and Pull of Mediastinum
a. Push  Pleural Effusion and Pneumothorax
b. Pull  Upper Lobe Fibrosis and Unilateral Collapse
2. Purse Lip Breathing
a. Seen in COPD, especially emphysema
b. Patient breathes out against a pursed lip, which helps in increasing the intrabronchial
pressure above the surrounding alveoli and prevents its collapse
3. Trial’s Sign
a. Lower 1/3 of Sternocleidomastoid shows a prominent clavicular head, showing a shift of
the trachea
b. Mechanism – when the trachea moves to one side the pre-tracheal fascia becomes
flabby and the clavicular head of the sternocleidomastoid becomes prominent
4. Causes for dropping of shoulder
a. Lung Pathology - Upper lobe fibrosis and collapse
b. Other - Shoulder dislocation and Clavicle fracture
5. Causes for increased VF/VR
a. Wherever there is Bronchial breathing
i. Consolidation and Cavity
6. Abnormal VF
a. Pleural Rub
b. Crepitation
c. Rhonchi
7. Abnormal VR
a. Whispering pectorliqy – sign in consolidation, able to hear patient whisper through steth
b. Bronchophonia – Can hear the words but no clarity
c. Egophonia – Goat Speech
d. Nasal Twang
8. Different notes in percussion
a. Normal is Resonant
b. Hyper-Resonant in Pneumothorax and Consolidation
c. Impaired to Dull in Fibrosis
d. Dull
i. Woody Dull – Consolidation
ii. Stony Dull – Pleural Effusion
9. Causes of obliteration of Cardiac Dullness
a. Left sided compensated Emphysema or simply emphysema
b. Left sided pneumothorax
c. Massive Pleural Effusion
10. Differences between Bronchial and Vesicular Breathing – Answer is above
55
11. Types of Crepitations
a. Fine – Fibrosis, Early Pleural Effusion
b. Coarse – Chronic Bronchitis, Late Pleural Effusion
c. Leathery – Bronchiectasis
12. Types of Rhonchi
a. Inspiratory or Expiratory
b. Monophonic or Polyphonic
c. Inspiratory + Monophonic  Foreign Body Obstruction
d. Expiratory + Polyphonic  Bronchial Asthma
13. Tidal Percussion
a. Percuss along the MCL with a held deep inspiration
b. If resonant than the pathology of dullness is probably below diaphragm
c. If dull than then pathology of dullness is probably above diaphragm
14. Shifting Dullness
a. Percuss the dullness  Shift patient to lateral  Dull becomes resonant
b. Horizontal Dullness
i. Percuss along MCL, Anterior and Posterior Axillary  Connect the dots after
percussion, a horizontal line is formed in hydropneumothorax
c. Ellie’s Curve – Connect the Dots of Pleural Effusion percussion
d. Succussion Splash – Keep steth at the horizontal line created, move the patient
vigorously, you will hear a splash sound as you auscultate (sloshing sound)
15. Post-tussive Suction, Post-tussive Crepitation
a. In a cavity keep the steth over the cavity you will hear a sucking sound over the cavity
and a crepitation after asking the patient to cough
16. Coin Test
a. In pneumothorax – Keep a coin anteriorly and steth on the opposite side, tap the coin
with another and the metallic tapping will be heard when auscultating
17. D’Espine Sign
a. In central segmental consolidation or Mediastinal tumors, you will get a tubular sound in
intrascapular area at the level of T4
18. Hamman Mediastinal Crunch
a. In mediastinal emphysema, auscultation over the sternum will give a pleuro-pericardial
rub due to pleuro-pericarditis
19. Ewart’s Sign
a. In massive pericardial effusion, due to compression there is lower segmental collapse
leading to tubular breath sounds in the left infrascapular area
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20. Kronig’s Isthmus
a. Boundaries
i. Medially – Line between the sternal end of clavicle and 7th cervical spine
ii. Laterally – Line joining the junction of medial 2/3rds of clavicle and lateral 1/3,
and junction of medial 1/3 of scapular spine with the lateral 2/3
iii. Posteriorly – Trapezius
iv. Anteriorly – Pectoralis and clavicle
b. Percuss medially to laterally, normally there is a band of resonance
c. There is obliteration of resonance in fibrosis
21. Types of Fibrosis
a. Focal Fibrosis – Pneumoconiosis
b. Replacement Fibrosis – Pulmonary Tuberculosis
c. Infiltration – Rheumatoid arthritis
22. Types of Collapse
a. Active collapse (absorption collapse) – Trachea is to the same side
b. Compression / Passive Collapse
i. Seen in pleural effusion
ii. Trachea is to the opposite side
23. Difference between Fibrosis and Collapse
24. Traube’s Space
a. Boundaries
i. Above – Diaphragm
ii. Below – 9th Rib
iii. Laterally – Spleen
iv. Medially – Left lobe of Liver
b. Normally tympanic on percussion due to normal content being the fundus of stomach
c. Dull on percussion: heavy meal, fundal tumors, massive pleural effusion, massive
splenomegaly, pericardial effusion, massive hepatomegaly of left lobe
25. Indications for Intracostal Drainage
a. Empyema
b. Pneumothorax
c. Hydropneumothorax
d. Massive Pleural Effusion
26. Classification of Respiratory Diseases
a. Obstructive Airway Disease – BA, COPD, Bronchiectasis
b. Restrictive – Pleural disease, Interstitial Lung Diseases, and Thoracic cage diseases
(kyphoscoliosis)
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27. Causes of Cavitatory Lesion
a. TB, Strep, Staph
b. CA Bronchus
c. Bronchiectasis and cystic bronchiectasis
d. Hydatid Cyst
e. Rheumatoid Nodules
f. Pulmonary Infarction
g. Wegener’s Granulomatosis
28. Foci of Pulmonary TB
a. Ghon’s Lesions
b. Ranke’s Complex
c. Simon’s Foci
d. Rich Foci – Endarteritis of the Brain
29. Indications for Steroids in TB
a. TB pericardial effusion
b. Miliary TB
c. TB Meningitis
d. Genitourinary TB
e. Addison’s Disease
30. Difference between pink puffers and blue bloaters
Pink Puffers
Blue Bloaters
No Cyanosis
Cyanosis
No Polycythemia
Polycythemia Present
CF and Respiratory Failure are Late
Early and Common
Long Duration to produce symptoms
Early symptoms, Shorter Duration
No Clubbing
Clubbing
31. Skodaic Resonance
a. Boxy type of percussion note just above the upper level of pleural effusion
32. Cor Pulmonale
a. Acute – Emergency Pulmonary Infarction, where immediate heart failure leads to death
b. Chronic – With or without heart failure, right ventricular dilatation with or without
hypertrophy due to increased Right ventricular afterload due to pulmonary hypertension
or chronic diseases of the lung skeletal abnormalities
33. Indications for surgery in Bronchiectasis
a. Massive Hemoptysis
b. If only one segment is involved  lobectomy
c. Repeated RTIs
d. If medical line of treatment fails  lobectomy
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34. Types of Cough
a. Dry – URTI
b. Productive – LRTI
c. Brassy – Loud and Metallic associated with subglottic edema
d. Barking – associated with croup (laryngotracheitis)
e. Whooping – Pertussis infection
f. Nocturnal – Feature of heart failure
g. Bovine – explosive nature, unable to close glottis
35. Predisposing Factors for Pneumonia
a. Immunocompromised
b. Diabetes
c. Old Age
d. Associated Renal Failure, Liver Failure, Smoking
36. Causes for Recurrent Pneumonia
a. Bronchiectasis
b. Immunocompromised status
c. Wrong Diagnosis
d. Choosing wrong Antibiotic
e. Foreign Body
37. Causes for Atypical Pneumonia
a. Mycoplasma
b. Coxiella
c. Chlamydia
38. Causes for Bilateral Pleural Effusion
a. All transudate effusions – Heart, Liver and Renal Failure
39. Cause for Hemorrhagic Pleural Effusion
a. Pulmonary TB
b. Pulmonary Infarction
c. Injuries and Trauma
40. Causes of Right Side Pleural Effusion
a. Cirrhosis
b. Cardiac Failure
c. Liver Abscess Rupture
d. Meigs Syndrome – Ascites and PE or Hydrothorax in association with a benign solid
ovarian tumor usually an ovarian fibroma
41. Causes of Left Side Pleural Effusion
a. Pancreatitis
b. Ruptured Esophagus
42. Difference between Transudate and Exudate in Pleural Effusion
a. Wright’s and Light’s Criteria
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43. Phantom Tumor (Vanishing Lung Tumor)
a. Fluid which exists due to pulmonary edema goes between the lobes of the liver
mimicking a tumor on imaging, however, they disappear on diuretics
44. Criteria to Diagnosis Acute Severe Bronchial Asthma (Status Asthmaticus)
a. Heart rate  >120
b. RR  >30
c. Pulsus Paradoxsus
d. pCO2  >50
e. pO2  <60
f. Inability to complete one sentence
g. Altered level of consciousness
45. What is Bronchiectasis sicca (dry)?
a. Upon coughing, the patient coughs up only blood, no sputum
46. Causes of Bronchiectasis
a. Infectious – TB
b. Obstruction – BCC, Lymphoma, FB
c. Congenital – Kartangener Syndrome, CF, Young’s Syndrome, Williams-Campbell
Syndrome, Marfan Syndrome
47. Complications of Bronchiectasis
a. Hemoptysis
b. Repeated RTI
c. Pneumonia
d. Metastatic Brain Abscess –Spread through paravertebral sinuses
e. Respiratory Failure
f. Amyloidosis
g. Cor Pulmonale
48. Hemoglobin Abnormalities in Cyanosis
a. Methemoglobinemia
b. Sulfhemoglobinemia
c. Carboxyhemoglobinemia
49. MRC Dyspnea Grading – mentioned above
50. Tongue in Clinical Practice
a. Pale – Anemia
b. Red (Angry) – Pellagra, sprue
c. White – patch of leukoplakia
d. Magenta – Riboflavin deficiency
e. Raspberry – Scarlet fever
f. Blue – Central cyanosis
g. Brown – Chronic Renal Failure
h. Purple – Polycythemia
i. Black – Iron toxicity
j. Strawberry – Scarlet Fever
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51. Types of Hemoptysis
a. Endemic – Lung Fluke
b. Pseudohemoptysis – Beetroot
c. Spurious Hemoptysis – URTI
d. Suppurative Hemoptysis – Foul Smelling
e. Frank Hemoptysis
52. Grading Hemoptysis
a. Mild - <100 ml/day
b. Moderate – 100-150 ml/day
c. Severe – 200-500 ml/day
d. Massive – 500ml/day or 150 ml/day
53. Cardiac vs. Respiratory asthma
54. Hoover’s Sign
a. In advanced COPD  Indrawing of intercostal space during inspiration
55. Surface marking of lobes of lung
a. Left side – Draw an oblique line to join from T2 behind around the lateral chest wall to
the 6th costal space. This divides the left lung into upper and lower
b. Right side – Draw a line at the 4th costal cartilage hitting a line similar to right lobe
obliquely
56. Miliary Motlings
a. 0.2-2 mm opacities seen in the lung
b. Causes:
i. Miliary TB
ii. Histoplasmosis
iii. Coccidiomycosis
iv. Coal Miner’s Pneumoconiosis
v. Sarcoidosis
vi. Hemosiderosis
vii. Silicosis
viii. Pulmonary Eosinophilia
57. Accessory Muscles of Respiration
a. Inspiratory
i. SCM
ii. Scaleni
iii. Pectoralis
iv. External Intercostal
v. Trapezius
b. Expiratory
i. Internal Intercostal
ii. Latissimus Dorsi
58. DOTS
59. MDR-TB
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Nervous System Viva Examination Questions
1. Classify Stroke
a. Complete Stroke – After 92 Hours
b. Stroke in Evolution – Due to thrombosis
c. TIA – Complete restoration of neurological function within 24 hours
d. RIND
e. Lacunar Stroke - ?
2. Neurological Manifestations of HIV
a. Meningitis
b. Encephalitis
c. Brain Stem Encephalitis
d. Myelitis
e. Peripheral Neuritis
3. Neurosyphilis
a. Meningovascular
i. Cerebral
ii. Spinal
b. Parenchymal
i. Tabes Dorsalis
ii. GPI – General Paralysis of Insane
4. Difference between Embolic, Hemorrhagic and Thrombotic Stroke
Embolic
Hemorrhagic
Thrombotic
Anytime
Evening
Early Morning
Accident History, RHD
Hypertension, Trauma
RHD, Hypertension
Convulsions Common
Can be seen
Rare
Features of ICT not common
Common
Not common
Sudden Onset
Sudden
Stroke Evolution
No Neck Rigidity
Neck Rigidity Seen
Not There
Clear
CSF Blood Stained
Clear
5. What is Apraxia?
a. Inability to perform the act in which patient is familiar with, in the absence of motor
weakness.
6. Dominant Cortex Lesion Functions
a. Speech
b. Apraxia
c. Acaliculia
d. Agnosia – Appreciate by structure
7. What is Crossed Hemiplegia?
a. 6 types
8. Cruciate Hemiplegia
a. Lesion is at decussation pyramidal tract
b. Weakness of hand on same side and leg on the opposite side
9. Incomplete Hemiplegia ???
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10. Stuttering Hemiplegia
a. 3-4 attacks of TIA
b. Then Complete stroke within 24 hours
11. ACA vs. MCA Lesion
a. ACA Lesion Weakness is more in the Lower Limbs than Upper Limbs and there is
Bladder involvement.
b. MCA Lesion weakness is more in the upper limbs (Dense Hemiplegia)
12. Carotid vs. Basilar Territory Lesion
Carotid Territory
Basilar Territory
Hemiplegia
Quadriplegia
Aphasia
Dysarthria
Homonymous Hemianopia
Dysphagia
Amourosis Fuax
Diplopia
Drop Attack
13. Features based on site of lesion
Site of Lesion
Cortex
Internal Capsule
Brainstem – Hemi-section
Brainstem – Complete section
High Cervical (Above C4) – Complete
Section
Mid-Thoracic
Hemisection of Spinal Cord
Type of Neurological Deficit
Monoplegia – Opposite Side
Hemiplegia – Opposite Side
Crossed Hemiplegia
- Same side CN Lesion
- Opposite side hemiplegia
Quadriplegia
Quadriplegia with CN Intact
Paraplegia
Brown-Sequard Syndrome
- Sensory Opposite Side
- Motor on Same Side as Lesion
- Posterior Column lesion features on
same side
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14. Blood Supply of Brain
Internal Capsule Blood Supply
15. What is primitive reflex?
a. Present at Birth
b. Disappears by one year of age
c. Some may reappear in old age
16. Signs of Meningeal Irritation
a. ?????
17. Bell’s Palsy
a. LMN type of Facial Palsy
b. Opposite side full
c. Causes of Bilateral Bell’s Palsy
i. Leprosy
ii. GB Syndrome
iii. Sarcoidosis
iv. Porphyria
v. B/L CSOM/ASOM
vi. Basal Meningitis
18. Glasgow Come Scale
a. Helps to assess the prognosis after a head injury
b. Spontaneous Eye Opening – 10 Points
c. Best Verbal Response – 12 Points
d. Best Motor Response – 20 Points
e. Overall Minimum should be 15
f. Worst Mortality is below 3
19. Mini-Mental Scoring
a. Orientation – 10
b. Registration – 3
c. Attention and Calculation – 5
d. Recall – 3
e. Language – 9
f. Max is 30, Normal is 27 or up, <23 is an altered MMS
20. Horner’s Syndrome
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a. Miosis, Ptosis, Enophthalmos, Anhydrosis
21. Grading of Tendon Reflex
a. 0 – Absent
b. 1 – Sluggish, Equivalent to Ankle Reflex
c. 2 – Normal
d. 3 – Exaggerated
e. 4 – Brisk
f. 5 – Clonus
22. Reinforcement
a. Jendrasik’s Maneuver
b. By this method the Anterior Horn Cells are in an irritated state
c. So small strike leads to a good reflex and prominent
23. Causes for Proximal Muscle Weakness
a. Painful Proximal Muscle Weakness
i. Osteomalacia
ii. Polymyositis
b. Painless Proximal Muscle Weakness – Peripheral Neuritis due to Demylination
i. GB Syndrome – Acute Inflammatory Demylination (Polyradiculopathy)
ii. Muscular Dystrophy
24. Types of Sensory Problems
a. Peripheral Nerve – Glove and Stocking Sensory Loss
b. Dorsal Root – Root Pain leads to Electrical Shock Pain
c. Cruciate (Intramedullary Lesion) – Dissociated Anesthesia, loss of pain and temperature
sensation, with retention of superficial touch
i. Syringomyelia – Trophic Ulcer
d. Posterior Column – Rombergism, as it becomes darker, the patient sways and falls
when closing their eyes
e. Lherrmitte’s Sign – Flex neck, a shooting pain to the arms occur, seen in cervical
spondylosis
25. TIA
a. Complete recovery of Neurological Deficit within 24 hours, usually 10 minutes
b. Types
i. Low Flow TIA
ii. Embolic TIA
iii. Lacunar TIA
iv. Vertibrobasilar TIA
v. Carotid TIA
26. RIND
a. Reversible Ischemic Neurological Deficit
b. Complete recovery within 2-3 Days
27. Argyll-Robertson Pupil
a. ???
28. Diabetic Ulcer??
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29. Bell’s Phenomenon
a. In Bell’s palsy eye lid does not close, the eye is seen and moving as normal. However,
the eye cannot be seen when the normal eyelid closes
30. Gag Reflex
a. Refer to CN – 9, 10
31. Direction of Nystagmus
a. Find direction by observing the past point or faster component
32. UMN vs. LMN????
33. Gower’s Sign
a. Proximal muscle weakness
b. Climbs on all four limbs
34. Beaver’s Sign
a. Lesion at T10
b. Ask patient to lift upper body, umbilicus moves up and protrudes
35. Abnormal Movements
a. Tremors – Rhythmical movement of a part of the body around a fixed point
b. Chorea – Pauci-movements, dancing like
c. Myoclonus – Sudden shock like movement of a part of the body
d. Fasciculation – irregular twitching of the muscle fibers, supplied by single motor neuron
unit
36. Saddle Anesthesia
a. Perianal area anesthesia
b. Conus caudal lesion, Tip of the Spinal cord
37. Sacral Spare
a. Throughout the body the sensation is lost
b. Sacral sparing is seen in intramedullary lesion, high thoracic
38. Superficial Reflex
a. Polysynaptic Reflexes
b. All are excitatory and pyramidal
39. Deep Reflex
a. Monosynaptic and Inhibitory
b. Because excitatory causes exaggerated reflex
40. Extensor Reflex other than pyramidal lesion
a. New born
b. Comatose Patient
c. Post epileptic fit
d. Deep Sleep
e. Alcoholic
41. Neurogenic Shock
a. In acute UMN lesions, reflexes are initially absent or sluggish, since the spinal cord is in
shock
b. 4-6 weeks for reflexes to get exaggerated
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42. Parts of Cerebellum and its Function
a. Arche-Cerebellum – Equilibrium
b. Palleo-Cerebellum – Muscle Tone and Posture
c. Neo-Cerebellum – Coordination and Skill Movement
43. Inverter
a. Inverter of Supinator
i. If lesion is exactly at C5, flexion of the distal phalanx is present but no supination
on supinator reflex
b. Inverter of Biceps
i. If lesion is exactly at C6, instead of flexion at the elbow there is extension
c. Inverter means – at the level of lesion there’s LMN features, below the level its UMN
44. Peripheral Nerve Palpitation – Many can be palpated in leprosy
a. Ulnar Nerve
b. Greater Auricular
c. Common Peroneal
d. Supraorbital
45. Other methods to elicit Babinski’s Sign
a. ????
46. Lacunar
a. Small capillaries, perforating branches of brain at the end of the ACA
b. May get infarcted
c. Can affect basilar or carotid territories
d. 0.2-2 mm in size
e. Types of Lacunar Infarcts
i. Pure Motor Hemiplegia
ii. Pure Sensory Stroke
iii. Ataxic Hemiparesis – Cerebellum
iv. Dysarthria
v. Clumsy Hand Syndrome
vi. Pseudobulbar Palsy – Above level of the pons
47. Neurocutaneous Markers
a. Adenoma Sebaceum
b. Café au lait Spots
c. Neurofibroma
d. Shagreen’s Patch – Tuberous sclerosis
e. Telangiectasia
f. Vascular Navi
g. Sturge Weber Syndrome
h. Craniovertebral Anomalies
i. Low Hairline – below C4
ii. Short Neck
i. Spine Bifida Aculta
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48. Elseberg Rule
a. U type of Motor Weakness seen in extramedullary tumor of spinal cord
49. Cortical causes for paraplegia
a. Falx cerebri tumor in center of cerebrum
b. Central hydrocephalus
c. Unpaired anterior cerebral artery infarct
d. Superior sagittal venous infarct
e. Cerebral Diplegia
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Cardiovascular System Viva Examination Questions
Mitral Stenosis Questions
1. Severity of MS by Echo
a. Normal Mitral Orifice: 4-6 cm2
b. Mild: 1.5-2.5 cm2
c. Moderate: 0.5-1.5 cm2
d. Severe: <0.5 cm2
2. Clinical MS Grading
a. It is the distance between the second heart sound and murmur
b. Shorter the murmur more severe is the MS
3. Symptomatic Grading
a. Mild - Exertional Dyspnea
b. Moderate – PND
c. Severe – Orthopnea
4. Complications of MS
a. Endocarditis
b. AF
c. Thromboembolism
d. Hemoptysis
e. Ortner’s Syndrome
f. Repeated Respiratory Tract Infection
g. Heart Failure
h. Right Side Failure
5. Mechanism of Hemoptysis in MS
a. Pulmonary Apoplexy – refers to hemoptysis that occurs from rupture of a bronchial vein
due to severe mitral valve stenosis causing pulmonary venous hypertension.
b. Thromboembolism  pulmonary infarction and hemoptysis
c. Repeated RTI
d. Pulmonary Edema
6. Cause of mid-diastolic murmurs at apex
a. RHD
b. Austin Flint Murmur
c. Carey Coombs Murmur
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7. Difference between RHD, Austin Flint and Carey Coombs Murmur
RHD
A-F Murmur
Carey Coombs Murmur
Opening Snap Present
Not Present
Not Present
S1 Loud
Soft
Soft
Presystolic Accentuation
Not Present
Not Present
Right Ventricular Hypertrophy
Left Ventricular Dilatation
Right Ventricular Hypertrophy
8. Causes for MS
a. RHD
b. Congenital MS
c. Hunter Syndrome
d. Hurler Syndrome
e. Drug: Methysergide
f. Carcinoid Syndrome
g. Amyloidosis
9. Lutembacher’s Syndrome – Congenital ASD with Rheumatic MS
10. Ortner’s Syndrome – Severe MS causes left atrial enlargement which compresses the
recurrent laryngeal nerve causing hoarseness of voice
Mitral Regurgitation Questions
11. Causes for MR
a. RHD
b. Congenital MR
c. Infective Endocarditis
d. Surgical Trauma – Trauma to Chordae Tendineae
e. CTD like RH
f. Marfan Syndrome
g. IHD
12. Cause for Pan-systolic Murmur
13. MR due to RHD, VSD, TR
RHD
VSD
TR as D/D
Heard at Apical Area
Just Left of sternum at 3rd, 4th, 5th
Epigastric Area
ICS
Left Ventricular Enlargement Bi-Ventricular Enlargement
Left Ventricular Enlargement
Better on Expiration
Not much change
Better on Inspiration
Radiates to Axilla
Complete Pericardium
Doesn’t Radiate
14. Complication of MR
a. Arrhythmias
b. Thromboembolism
c. Endocarditis
d. Heart Failure
15. Differences between Acute and Chronic MR
a. Acute – No heart Enlargement, Chronic – Heart enlargement, Peripheral signs present
Aortic Stenosis Questions
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16. Severity of AS – Grading
a. Mild - >0.7 cm2
b. Moderate – 0.5-0.7 cm2
c. Severe – <0.5 cm2
17. Causes of AS
a. RHD
b. Congenital
c. Degenerative Diseases
d. Calcium Deposition
18. Cardinal Signs of Aortic Stenosis
a. Angina
b. Syncope
c. Breathlessness
19. Gallavardin Phenomenon
a. Dissociation between noise and musical components of systolic murmur
b. Harsh noisy component best heard at upper right sternal border radiating to neck due to
high velocity jet in the ascending aorta
c. Musical component is best heard at the cardiac apex – this can be misinterpreted as
Mitral Regurgitation
Aortic Regurgitation Questions
20. Causes of AR – Same as MR
21. Difference in Acute and Chronic AR – Same as MR
22. Difference between Syphilitic AR and Rheumatic AR
Syphilitic AR
Rheumatic AR
Aortic Area
Erb’s Area
Angina Present
Not Present
S2 Muffled
S2 Loud
Isolated
Multi-Valvular
VDRL Positive
Not Positive
ASLO Negative
ASLO Positive
Peripheral Signs Present
Not Present
23. Peripheral Signs of AR
a. Light House Sign – Blanching of forehead on diastole, Flushing on systole
b. Landolfi’s Sign – Alternate dilatation and contraction of pupils, when systole it contracts,
and diastole it dilates
c. Muller’s Sign – Pulsating Uvula
d. De Musset’s Sign – Rhythmic nodding or bobbing of head in synchrony with heart
e. Becker’s Sign – Pulsation of Retinal arteries
f. Quincke’s Sign – Nail bed pulsation
g. Corrigan’s Sign – Water-hammer Pulse
h. Traube’s Sign – Pistol shot sound heard over femoral
i. Duroziez’s Sign – Murmur heard over femoral artery, when compressing distally a
diastolic murmur is heard, when compressing proximally a systolic murmur heard
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Hill’s Sign – Significant difference in lower limb BP (popliteal) being more than upper
limb BP (Brachial), on the same side
i. Normal - <20mmHg
ii. Mild AR – 20-40 mmHg
iii. Moderate AR – 40-60 mmHg
iv. Severe AR - >60 mmHg
k. Rosenbach’s Sign – Pulsatile of the Liver
l. Gerhardt’s Sign – Enlarged Spleen
m. Shelly’s Sign – Pulsation of Cervix
n. Sherman’s Sign – Easily detectable Dorsalis Pedis pulse in >75 years
o. Mayne’s Sign – Decrease in DBP of 15 mmHg when arm is held above the head
p. Lincoln’s Sign – Visual pulsation of Popliteal artery
q. Ashrafian’s Sign – Pulsatile pseudo-proptosis
24. Complications of AR
a. Endocarditis
b. Arrhythmia
c. Heart Failure
j.
General CVS Questions
25. Differences between Pericardial Rub and Murmur
Pericardial Rub
Murmur
Due to Pericarditis
Due to Valvular Damage
No Radiation
Radiates
Heard Sound Won’t Change
Heart Sound Changes
No Cardiomegaly
Cardiomegaly May be Present
Local Tenderness
No Local Tenderness
No variation in Pitch
Pitch Varies
26. Influence of Exercise on Murmurs – Dynamic Auscultation
a. All Stenotic murmurs are better heard during isometric exercises
b. All Regurgitant murmurs are better heard during hand grip
c. HOCM (Hypertrophic Obstructive Cardiomyopathy) however is heard less on hand grip
27. Differences between Arterial and Venous Pulse
Arterial Pulse
Venous Pulse
Better Felt
Better Seen
Cannot Obliterate
Easily Obliterated
Carotid – Medial to SCM
Jugular – Lateral to SCM
Spike on Palpation
Wave on Palpation
No variation on respiration
Varies on Respiration
28. Austin Flint Murmur
a. Functional Mid-Diastolic murmur in Severe AR
b. Best heard at Apex
29. Carey Coombs Murmur
a. Mid Diastolic rumble caused by mitral valvulitis of RF
b. Best heard at Apex
c. No Opening snap (as compared to diastolic murmur of MS)
72
30. Graham Steell Murmur
a. Associated with Pulmonary Regurgitation
b. High pitched Early Diastolic Murmur
c. Best heard in Pulmonary Area
d. Due to high velocity flow through Pulmonary Valve, a consequence of Pul HTN
31. Gibson’s Murmur
a. Associated with PDA
b. Described as a Machinery Murmur due to its continuous nature
c. Due to Higher pulmonary pressure of PDA
32. Roger’s Murmur
a. Associated with small VSD
b. Loud Pan-Systolic Murmur
33. Changing Murmur
a. Murmur changes in intensity – associated with infective Endocarditis
34. Functional Murmur
a. A murmur due to a physiologic condition outside the heart
b. Ex: Anemia, pregnancy, fever, thyrotoxicosis
35. Abdominal-Jugular Reflux (AJR)
a. Patient lying down at 30 degrees with head turned to opposite side
b. Pressure on the Right Hypochondrium of abdomen for 30 seconds
c. Positive result: Sustained rise of JVP of at least 4 cm after the examiner releases the
pressure – Seen in RVF, about 1 cm rise normally
d. Negative result: a lack of rise in JVP due to Budd-Chiari Syndrome
36. Peripheral Signs of Infective Endocarditis
37. Abnormal Pulse
a. Anacrotic
b. Diacrotic
c. Pulsus Bisferens
d. Pulsus Paradoxsus
e. Pulsus Bigeminus
f. Water Hammer Pulse
g. Pulsus Parvus et artlus
38. Eisenmenger Syndrome
a. Causes – Other than VSD
b. Long standing Left to Right shunt causes Pul HTN and eventual reversal of shunt to
Right to Left causing a cyanotic shunt
39. Eisenmenger Complex
a. Caused specifically by VSD
40. Mechanism of PND
a. Detailed above
41. Mechanism of Orthopnea
a. Detailed above
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42. Indications of Percussion in CVS
a. Pulmonary Hypertension – Dull Right Second Space
b. Pericardial Effusion
c. Diabetic Dilated Cardiomyopathy
43. Contraindications of Percussion in CVS
a. Aneurysm of Ascending Aorta
b. Local Tenderness
c. Arterial Myxoma
d. Arterial Fibrillation
e. Suspected Infective Endocarditis
44. Conditions where Apex is not seen
a. Physiological condition – Behind Rib
b. Abnormal condition
i. Pericardial Effusion
ii. Obesity
iii. Emphysema
iv. Pneumothorax
45. Parasternal Heave Grading
a. Grade 1 – Not seen
b. Grade 2 – Seen, felt but can obliterate
c. Grade 3 – Seen, felt, cannot obliterate
46. JVP
a. Discussed above
b. Absent in Atrial Fibrillation
47. Causes of Malar Flush
a. SLE
b. RA
c. MS
d. ALD
48. Tracheal Tug (Oliver’s Sign)
a. Seen in Aneurysm of Arch of Aorta
b. Abnormal downward movement of trachea during systole
c. Done by gently grasping the cricoid cartilage and applying upward pressure. Due to
anatomic position of arch of aorta, which overrides the right main bronchus, a downward
tug is felt on each systole is an aneurysm is present
49. Mechanism of Collapsing Pulse in AR
a. Due to run back phenomenon
50. Blood Culture in Endocarditis
a. Two samples in different areas with a 30-minute gap, with good aseptic conditions
b. If negative, redo in 2 hours
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51. Jones Criteria for RHD
Major Criteria - JONES
J – Joint Involvement (Arthritis)
O (Looks like Heart) – Myocarditis
N – Nodules, Subcutaneous Nodules
E – Erythema Marginatum
S – Sydenham Chorea
Minor Criteria – CAFÉ PAL
C – CRP Increased
A – Arthralgia
F – Fever
E – Elevated ESR
P – Prolonged PR Interval
A – Anamnesis (History) of Rheumatism
L - Leukocytosis
a. Diagnosis
i. Throat Culture growing Group A Beta Hemolytic Streptococcus
ii. OR Elevated ASO Titres
iii. PLUS
1. 2 Major Criteria
2. OR 1 Major and 2 Minor Criteria
52. Prophylaxis for RF
a. Benzathine Penicillin 12 Lakhs Deep IM once in 3 weeks
53. Prophylaxis for IE
a. For Dental Procedures
b. 3 gm of Amoxicillin, 30 minutes before procedure
c. For GI Surgery - ?
d. For Neuro Surgery - ?
54. Causes of Erythema Nodosum
a. Sulfonamides
b. TB
c. Sarcoidosis
d. Leprosy
e. IBD
f. Toxoplasmosis
55. Painful Clubbing
a. Bronchogenic CA
b. Infective Endocarditis
c. Lung Abscess
56. Excessive Clubbing
a. Lung Abscess
b. Emphysema
57. Mechanism of Clubbing in Liver Disease
58. Relative Bradycardia
a. A HR that although not actually below 60 bpm is still considered slow for the individual’s
current medical condition
b. Seen in Pyogenic Meningitis, Brucellosis, Weil’s Disease, Enteric Fever
59. Relative Tachycardia
a. HR is seen to be higher, and is normal for the condition of the patient
b. Carditis, TB, Myocarditis
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60. Epigastric Pulsation
a. Insert the thumb below the xiphisternum
b. Impulse felt at tip – from Right Ventricle
c. Impulse felt at pulp of finger – from aorta
61. Smoking Index
a. Number of Cigarettes per day x Years of smoking
b. Grading
i. Mild <100
ii. Moderate 100-300
iii. Heavy >300
62. Pack Years
a. Number of packs per day x Years of smoking
b. Or Smoking index / 20 (As there are 20 cigarettes in a pack)
63. Non-Cardiac causes for Orthopnea
a. Massive Ascites
b. Massive Pleural Effusion
c. Severe Asthma
d. Emphysema
64. Platypnea
a. Breathlessness while standing or sitting but relieved on lying down
b. Seen in:
i. Hepatopulmonary syndrome
ii. Right to Left Shunt
65. Trepopnea
a. Breathlessness on lying on lateral recumbent position
b. Results in disease of one lung, patient prefers to lie on opposite side of diseased lung,
lying on the side of the healthy lung improves perfusion of the same lung
c. Patients of Heart failure prefer lying on right lateral to improve cardiac return
66. Cooing Dove Murmur
a. High Pitched musical quality murmur associated with aortic regurgitation and MR with
endocarditis
b. It is a diastolic murmur heard over the precordium
67. Kussmaul Sign
a. Paradoxical rise in JVP on inspiration
b. Due to limited right ventricular filling due to right heart failure
68. Hamman’s Sign
a. Crunching, rasping sound, synchronous with heart beat heard over the precordium due
heart beating against air-filled tissues in emphysema
69. Homan’s Sign
a. Calf pain on dorsiflexion of the foot or squeezing of the calf is thought to be associated
with presence of a deep vein thrombosis
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70. Metabolic Syndrome
a. Central Obesity with 2 of the 4 below
i. Increased Triglycerides
ii. Reduced HDL Levels
iii. Increased BP
iv. FBS >100
71. Different Nodes
a. Heberden’s Nodes – Hard or bony swellings that can develop in Distal interphalangeal
joints, a sign of osteoarthritis
b. Osler’s Nodes – Painful, red, raised lesions found on hands and feet associated with IE,
SLE, disseminated gonococcal infection
c. Aschoff Nodules – Found in the heart of people with RF, results due to local
inflammation
d. Rheumatoid Nodules – Local swelling, firm on touch occurs exclusively in RA
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