Clinical Examination Skill (Step by Step)

Step by Step
Clinical Examination Skills

Step by Step
Clinical Examination Skills
Farrukh Iqbal
MBBS (Pb) MRCP (UK) FRCP (Edin) FRCP (London)
Professor of Medicine
Shaikh Zayed Postgraduate Medical Institute
Consultant Physician
Shaikh Zayed Hospital
Lahore, Pakistan
Foreword
Muhammad Akbar Choudhary
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Step by Step Clinical Examination Skills
2009, Farrukh Iqbal
All rights reserved. No part of this publication and Interactive DVD ROMs should be reproduced, stored
in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every
effort is made to ensure accuracy of material, but the publisher, printer and author will not be held
responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled
under Delhi jurisdiction only.
First Edition: 2009
ISBN 978-81-8448-642-1
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset & Packagings Ltd., New Delhi
FOREWORD
I am delighted to write a Foreword to this book which

is written by a clinician and a medical educator, who has
an excellent academic record throughout his career.
This book lays special emphasis on bedside medicines
and gives an excellent concept of clinical skills, the
backbone of a thorough clinical examination which
ultimately leads to a proper diagnosis and hence the
management. Each system has been divided into different
sections and a beautiful attempt has been made for the
step-by-step examination of each part, hence the name
Step by Step Clinical Examination Skills.
Simple, readable and fluent presentation adds to the
value of this book. One feels pleasure and satisfaction after
going through it. This book shall prove an extra aid to
under and postgraduate medical students who are
preparing for the clinical part of their FCPS (Medicine),
MRCP (UK) and MD (Medicine) examinations. The
addition of interactive DVD-ROMs will further add to its
value as a visual impact is long lasting.
The script is simple to follow and comprehend by the
readers. Being myself, a life long teaching physician in
a clinical setting, I find this book an excellent contribution
to the subject of clinical medicine.
vi CLINICAL EXAMINATION SKILLS
I have full confidence that this book will receive respect

and admiration from the medical community and will be
a valuable addition to other books on clinical examination
and will prove to be an excellent companion for the
medical students.
Prof Muhammad Akbar Choudhary
MRCP (UK) FRCP (Edin) FRCP (Lon) FPAMS (Pak) FACC (USA)
Principal, Professor and Head
Department of Medicine
Fatima Jinnah Medical College
Sir Ganga Ram Hospital
Lahore, Pakistan
International Advisor
Royal College of Physicians of London, UK
Member Surveillance Regional Advisory Group
WHO EMRO Region
Member Influenza Pandemic Task Force, WHO
PREFACE CONTENTS vii
The field of medical science is extremely vast and it

encompasses many disciplines. The art of clinical
examination at the bedside of the patient can only be learnt
with continuous practice and with the help of standard
textbooks on this subject.
In this book, an attempt has been made to write
examination of the clinical skills in an easy and
understandable way. I would request the readers to go
through it from the beginning and I am sure that they
will definitely enjoy it. The language is very easy and
comprehensible and emphasis has been laid on to keep
the continuity of the material discussed in the relevant
sections.
Farrukh Iqbal
ACKNOWLEDGEMENTS
I feel immense pleasure to thank all my teachers,

colleagues and especially my students who motivated me
to write this book.
I am indebted to my mentor, Dr Asif Kamal FRCP
(London), FRCP (Edin), Consultant Physician, Lincoln County
Hospital, Lincoln, Lincolnshire, UK and Chief Investigator
for PLAB (GMC London) for perpetually encouraging me
to write for medical students.
I am thankful to my colleague Dr Atiya Mahboob FCPS
(Derm), Associate Professor of Dermatology for writing a
very useful chapter on dermatological examination. She
always came up with academic activity whenever she was
asked.
I am also indebted to Dr Shahid Anwar FCPS (Neph)
for writing useful chapter on nephrological examination.
I am grateful to Dr Muhammad Suhail M Phil (Anatomy)
Associate Professor of Anatomy for reviewing the chapter
on Neurological and Musculoskeletal System Examination.
It would not be fair if I do not mention the name
of Mr Shahid Rauf for efficiently typing and formatting
the manuscript of this book.
Last but not the least, I am thankful to my wife Shahina,
my daughters Saliha and Zunaira and my son Aizad for
extending their full cooperation while writing this book.
I shall warmly welcome any comments and suggestions
regarding this book to improve it further in future.
CONTENTS
1. Introduction .................................................................. 1
2. Skills in Medical Education ..................................... 9
3. History Taking ........................................................... 13
4. Instruments Required .............................................. 23
5. General Physical Examination ............................... 25
General Instructions .................................................. 27
Case Writing Tips ..................................................... 31
Step by Step Examination of the
Patient as a Whole .................................................... 32
Common Commands ................................................. 36
6. Examination of Respiratory System ..................... 65
Principles of Examination of
Respiratory System .................................................... 66
Step by Step Examination of
Respiratory System .................................................... 72
Case Writing Tips ..................................................... 74
Common Commands ................................................. 76
7. Examination of Cardiovascular System ............... 93
Principles of Examination of Cardiovascular
System .......................................................................... 94
Step by Step Examination of Cardiovascular
System ........................................................................ 102
Case Writing Tips ................................................... 104
Common Commands ............................................... 107
8. Examination of Gastrointestinal System
(Abdomen) ................................................................ 123
Principles of Examination of Gastrointestinal
System ........................................................................ 124
Step by Step Examination of Alimentary
System ........................................................................ 130
x CLINICAL EXAMINATION SKILLS

Common Commands ............................................... 137
9. Examination of Genitourinary System .............. 157
Check List for Nephrological
Examination .............................................................. 158
10. Examination of Nervous System ........................ 165
Basic Principles ........................................................ 166
Neurological Examination as a Whole ............... 168
Common Commands ............................................... 176
Cranial Nerves ......................................................... 181
Motor System ............................................................ 215
Check Power of the Individual
Muscles ...................................................................... 220
Muscles of the Upper Limb .................................. 221
Abdominal Muscles ................................................. 241
Trunk Muscles .......................................................... 242
Muscles of Lower Limbs ........................................ 244
Coordination of Movements .................................. 254
Reflexes ...................................................................... 258
Superficial Reflexes ............................................ 258
Deep Reflexes ..................................................... 264
Miscellaneous Reflexes ..................................... 273
Gait ............................................................................. 276
Involuntary Movements .......................................... 277
Sensory System ......................................................... 281
Superficial Sensations ....................................... 281
Deep Sensations ................................................. 285
Cortical Sensations ............................................ 290
General Principles for Examining
Sensory System ......................................................... 295
Cerebellar System ..................................................... 297
CONTENTS xi
Signs of Meningeal Irritation ................................ 299

Check for Brainstem Death or Brain Death ...... 306
Check Elicit Pain in the Patient .......................... 307
Elicit Focal Neurological Signs in an
Unconscious Patient ................................................ 309
11. Dermatological Examination ................................ 313
Principles of Dermatological Examination ......... 314
Step by Step Examination of the Skin ................ 315
12. Examination of Musculoskeletal System .......... 321
Principles of Examination of Musculoskeletal
System ........................................................................ 322
Examination of Musculoskeletal System ............. 325
Examine this Patients Vertebral Column ............. 331
Examination of the Upper Limb .......................... 336
Examine the Hands ................................................ 344
Examine the Knee Joint .......................................... 348
13. Patients Record ....................................................... 355
14. Investigations ........................................................... 359
Routine Investigations ............................................ 361
Systemic Investigations ........................................... 362
Bibliography ....................................................................... 369

Index ....................................................................... 371
CHAPTER 11
INTRODUCTION
Introduction
2 CLINICAL EXAMINATION SKILLS
The value of clinical medicine cannot be denied even in

this modern era of medicine where most sophisticated tests
and investigations are available in many teaching
hospitals and medical centres. During the last three
decades, numerous sensitive, specific and complicated
laboratory investigations have been in fashion to reach
and confirm a diagnosis and every day their number is
increasing and the methodology continues to change.
However, these are very expensive tests and the afford-
ability is sometimes beyond the capacity of a common man.
Therefore, it is very important to emphasize on clinical
acumen so that common illnesses are diagnosed and
treated promptly, rather waiting for the laboratory tests.
This does not mean that the importance of these tests is
denied. They are of course a great help in this context.
The laboratory investigations cannot supersede a good
clinical acumen and these are required to establish or
exclude a diagnosis. This point has to be emphasized on
young doctors during their training. A sound knowledge
of clinical examination skills can make these young doctors
super clinicians of the future. It is better to realize this
earlier than later.
It is rightly said that medical knowledge is a science
but on the contrary medical practice is an art. We have
seen many doctors over the years who had blooming
knowledge of medicine but ultimately they were not
successful as a good practitioners which ultimately matters.
There is no doubt that a sound basic knowledge in
a particular field makes a strong foundation but its
application in a right way is most important. Above all,
a good practitioner should be a good human too. The
doctor-patient relationship is very pious and taking a
detailed history and a physical examination assures the
patient that the doctor has done his best to diagnose his
INTRODUCTION 3
ailment and this further builds the confidence of the patient

and he becomes more co-operative. It is very well-said that
clinical medicine blossoms human medicine into humane
medicine. Clinical diagnosis and assessment of severity of
disease are based on history, thorough clinical examination
and investigations and the importance of these three
sources is well known to every good clinician.
It is also worth noting that when medical students enter
from the basic sciences of anatomy and physiology to the
clinical years, they are in a different environment because
there they were learning with frogs, dogs, rabbits and dead
human bodies (cadavers), but now they will learn on living
humans with various diseases. There will be both male
and female patients and understanding and respecting
their feelings is most important. This leads us to say that
good mannerism, kindness and politeness do matter a lot.
This approach makes the patient realize that this particular
doctor is kind, friendly and is interested to treat him or
her. To learn on the living human patients one needs their
co-operation and one should be grateful to them that they
have co-operated with their full effort in spite of infirm
health. Otherwise, if the patient does not co-operate then
learning clinical medicine and mastering clinical
examination skills may become very difficult and not less
than a major problem.
Clinical methods are the skills which every doctor
should achieve before they enter in real independent
clinical practice. As it is obvious, this skill is acquired
during a life time of practice. No doubt the methods in
clinical examination keep on evolving and changing but
not to such an extent as laboratory investigations. Clinical
skills are learnt by a combination of mutual study and
experience.
It is also important to know that various teachers have

their own way of examination of different systems but all
of them have some basics in common which is a healthy
exercise. Sometimes students experience difficulty from this
while in actual examination. It is therefore advised that
all the doctors should follow a well-known standard text
book of clinical examination and can quote reference from
that book to the examiner rather than naming a particular
person, which the examiner may not like. But undue
argumentations should not be done with the examiner on
these points of controversy as the candidates should not
take any risks at all during examination.
DC Corrigan (1802-1880) a renowned clinician said,
The trouble with doctors is not that they dont know enough,
but they dont see enough.
The skills required for a competent clinical examination
can only be learnt and mastered by practice at the bed
side of a patient. Each patient is like a book and unless
you open it and explore, you would not get enough
knowledge about the disease. It is also worth noting that
few patients have multiple pathologies and one can come
across these problems very often and should be able to
tackle them with confidence. A thorough basic knowledge
of anatomy, physiology and pathology adds towards
perfection.
It is also important to note that most medical problems
can be solved by a careful history and clinical examination
without subjecting the patient to many unwanted,
expensive, undesired and painful investigations.
The author has tried to put his experiences as a student,
teacher, examiner and a practitioner in this book. A lot
of care has been taken to design this book to create interest
in the medical students, both undergraduate and post-
graduate to understand importance of clinical examination
skills.
INTRODUCTION 5
This book will not only enhance the clinical knowledge

of already practicing clinicians but will also help
tremendously to undergraduate and postgraduate medical
students to get through their examinations, i.e. MBBS
(final), MCPS (Medicine), MD (Medicine), FCPS (Medicine),
MRCP (UK) and other medical examinations.
The set up of this book is simple and effort has been
made to discuss part of the examination step-wise thus
the name step by step in clinical examination skills.
Various commands given by the examiners to the examinee
from various systems have been described. Help of
photographic material is also provided to the student in
the book. A few examples of various commonly asked
commands are quoted below:
Examine this patients pulse
Examine the fundus of this patient
Look at this patients face and do the relevant
examination
Listen to the pre-cordium.
It is therefore of utmost importance to listen carefully
what the examiner says about the command or read
carefully if the command is written on a piece of paper
at the patients bedside and proceed accordingly, rather
than going into more details of those aspects which are
not asked at all. Time factor is very vital in these
examinations and you have to satisfy the examiner that
you know the art of doing clinical examination perfectly
under examination environment and under the specified
time limit. It may be difficult but by no means impossible.
The answer to this difficulty is to do more practice of
clinical examination even on normal human subjects, e.g.
your brother, friend or colleague etc. It is an old but well
said saying practice makes one perfect therefore get yourself
awake, tighten up all your strengths, straighten your aim,
spend your time honestly with the patients and practice

day and night and I can assure you that you will feel
that you have achieved confidence in examining the
patients correctly.
Also remember that for a good clinical examination,
besides basic working knowledge you should also be well
equipped with your instruments of basic needs which
should be kept in order in a small brief case. At times
I have seen students searching their pockets for needles,
measuring tape, ophthalmoscope or a tongue depressor
which wastes a lot of important and vital time which can
be spent in a more useful and fruitful way on the patient.
In the end a well-dressed, groomed, well and soft
spoken clinician adds to the beauty of the all this drill.
You should have nails and beard (if you have it) trimmed,
or clean shaved with polished shoes. But this does not
mean that you should think that by examining the patients
you will get dirty rather it is impressive to the examiner
and the patient.
When I appeared for my membership examination
(MRCP) in London in 1986, I was told by my teachers
that even if you are wearing a three piece brand new suit
and if you have to examine abdomen at the level of the
bed, kneel down on the ground! This further adds to the
confidence of the patient and gives impression to the
examiner that how dedicated you are in conducting a
thorough clinical examination. I was told by a very eminent
teacher that in the examination it is not only the knowledge
we test but we also take notice of the overall appearance
of the examinee and his mannerisms. The examinee may
be very good in knowledge but if the bed side manners
are bad then the chances of that candidate to pass are
very grim.
I must also stress that the history and a thorough
physical examination are two important pillars in patients
INTRODUCTION 7
management to follow later. If you want to become an

accomplished physician or clinician, you have to polish
your clinical skills and should continue polishing it for
the rest of your life. The experience grows and expands
identifying the symptoms, problems and abnormal
findings, listing them to an underlying process of
pathophysiology and establishing a set of most relevant
laboratory investigations more easily.
Bern and Lown said that todays physicians seem at times
more interested in laying on tests than laying on hands. Sir
William Osler, another renowned clinician once said
medicine is an art of probabilities and a science of uncertainties
and that these aspects are inseparable very much like
Siamese twins for whom trying to separate one from the
other would only kill them both.
Sir William Osler encouraged students of medicine in
almost all his books. In one of his books, he has written
learn to see, learn to hear, learn to feel, learn to smell and to
know that by practice alone you can become an expert. It still
applies in this modern era of science and technology. We
need to listen to our patients very patiently; we need to
understand their complaints or symptoms and we need
to observe them with critical sense to elicit physical signs.
These skills can be achieved by every doctor but require
sincere and strenuous effort and perpetual practice.
I would request the readers that having passed their
examinations; they should continue following the best of
clinical examination skills in future and pass on their
knowledge to their students and juniors.
In the end, I must thank all my students and colleagues
who continuously hammered me to write a book in a
simple and easy way to learn the clinical skills in physical
examination. I have tried to write very simple language
and hope that this will be another useful addition to a
treasure of books on this subject.
CHAPTER 92
SKILLS IN MEDICAL EDUCATION
Skills in Medical
Education
When a new medical graduate is given responsibilities

to look after a patient, he has to develop certain others
skills as well which will help him in attaining full
responsibility and therefore appropriate management of
the patient. Those skills are mentioned in a little detail
as follows:
COMMUNICATION SKILLS
A doctor should be able to communicate with the patient
in patients own language and should be versatile. Rarely
there is a need for an interpreter. Having mastered the
linguistic aspect of communication skills, one should be
able to discuss difficult problems with the patient in an
easy and understandable language if they have serious
illness and the doctor should also be able to break bad
news to the patient in such a way that does not hurt him
too much. He should also be able to consent with the
patient, his relatives and other logistic aspects and should
be able to make them understand the condition of the
patient if communicating to the relatives. The doctor should
be able to communicate and discuss the patients problems
with his other colleagues, seniors, nurses and other
personnels involved in the patients care.
CLINICAL SKILLS
They will be described in detail later but are summarized
as follows:
i. Take good history, physical examination and suggest
appropriate investigations.
ii. The interpretation of the history obtained and of any
signs which were picked up in the physical
examination and evaluation of the investigations.
SKILLS IN MEDICAL EDUCATION 11
iii. Make a list of the problems with the patient and with
the most important one on the top and then try to
unwind those problems one by one with appropriate
justification for further investigations.
iv. Utilize the hospital and social services for the
diagnosis and management of the patient.
v. Consolidate clinical knowledge with evidence based
scientific and clinical facts and facts from other
resources.
ORGANIZATIONAL SKILLS
The good doctor utilizes the facilities and resources
available in that particular hospital where he is working.
He should, therefore be able to organize such facilities
locally and in other hospitals.
CLERICAL SKILLS
These involve recording and updating patients record,
properly filling of the forms for different investigations,
appropriately doing the discharge summaries and writing
down the daily progress notes as follows, i.e. one should
use the synonym SOAP where S stands for Subjective
assessment, in other words symptoms of the patient,
O stands for Objective assessment, in other words
signs, A stands for overall Assessment after
considering these symptoms and signs and P stands
for working Plan for the patient. It is so easy to
remember!
ETHICAL SKILLS
These are of utmost importance now-a-days and one
should be well aware of this aspect of medicine in the
present era. There is plenty of material on this subject in
some good Textbooks of Medicine.
PROCEDURAL SKILLS
These include carrying out simple bed side or ward side-
room procedures, e.g. insertion of intravenous cannulae,
nasogastric tubes, putting up an infusion, pleural aspira-
tion, peritoneal aspiration, and insertion of indwelling
urinary catheters etc.
Last but not the least a doctor should be skilled enough
to manage most common medical emergencies and should
ask for help from his seniors if need be arise. He should
have a keen sense of observation while working with his
seniors.
It is important to mention that having acquired all these
skills, one should undergo self-assessment now and then,
to become aware of the fact whether he has achieved
whatever he wanted to. It is better to keep record of all
the activities performed during ones career but this may
seem very cumbersome for some individuals. (The College
of Physicians and Surgeons Pakistan has made it
compulsory for the candidates for FCPS (Medicine) to keep
all the record of patients and clinical procedures performed
during their period of training).
Auditing is a new aspect of all these activities and
this reminds one of ones mistakes so that they should
be corrected and not to be repeated in future.
Reviews by seniors or peers are also important and
make the basis of good reference for next career post.
In conclusion, postgraduate medical education continues
into life long medical education and one keeps on learning
new things in ones life perpetually and should have a
desire to remain abreast with the current knowledge. This
will assure the individual that they are providing optimal
care to the patient and therefore they should be satisfied
of achieving their aim by serving humanity.
CHAPTER 13
HISTORY TAKING
3
History Taking
History taking is the foundation pillar of patients manage-

ment and it should be recorded in patients own language
without involving too many technical terms. It should be
elaborate and encompass the patients data and details
of the symptoms, a systemic review and other components.
There are so many books only on clinical examination
which have comprehensive chapters on history taking,
therefore I have skipped that from this book but have
outlined major headings based on which one can get a
comprehensive history from the patient including all its
aspects.
Patients data, i.e. name, age, sex, address, telephone
number, medical record number, profession, marital status,
number of children, social status, monthly income
residential accommodation, etc. should be recorded
comprehensively for future reference.
HISTORY OF PRESENT ILLNESS

1. Chief complaints or presenting complaints should be
noted down in chronological order with the most
important complaint on the top with its duration.
2. History of present illness should elaborate all the
presenting complaints one by one in more detail. Patient
should be allowed to narrate his own story in his own
words without being prompted. Then one should ask
specific questions using words or terms which can be
readily understood by the patient. If the patient is a
poor historian or cannot give an appropriate history,
then help of immediate relative should be sought. It
should also be documented that the history was taken
from the friend or relative of the patient.
3. Previous history of present complaints is also worth
noting as patient may be having these symptoms in
the past including any treatment or investigations.
HISTORY TAKING 15
PAST MEDICAL HISTORY

One should carefully outline the details of any illnesses,
hospitalizations, surgical operations or procedures and
accidents in the past with exact or approximate dates. This
may or may not be related to the current illness. Chronic
illnesses should also be noted.
FAMILY HISTORY
It is important to note down any history of illnesses in
the family, i.e. parents, uncles, aunts, brothers and sisters
especially in context with the current illness.
PERSONAL AND SOCIAL HISTORY

Ask about the details of work and income, the
accommodation and whether living with family or alone.
Then ask about the number of children, and whether the
patient is married, divorced or separated etc. Whether
smoker, if so how many pack years of smoking. Ask about
any history of alcohol intake and if so how much and
how often and type of the hard drink. Ask about any
history of substance or drug abuse.
MENSTRUAL HISTORY
This is important to ask from all female patients. The onset
of menarche, the regularity of menstrual cycle, the quantity
of blood loss per menstrual cycle and the age of menopause
and then any dysfunctional uterine bleeding are important
questions to be asked. Ask about use of contraceptive pills
and any vaginal discharge.
DRUGS AND ALLERGIES

Note down any history of drugs (Medicines) being taken
by the patient at present or in the past for any illness.
It is often useful to see the pills oneself if the patient has

brought them to the clinic or to the hospital. Allergies to
any drugs should also be noted but it is important to probe
in this aspect in more detail to elicit what does the patient
mean from allergy?
NEGATIVE DATA
Sometimes it is important to ask and record a symptom
which was not present if you suspect a disease as your
diagnosis. Having had a detailed account of the history,
it is time to go for a systemic review. As you know, patients
presenting complaints are pertaining to one major system
commonly but enquiries should be made for symptoms
from other systems which may be directly or indirectly
related to that particular disorder. A list of non-specific
symptoms should also be noted. In this book only the main
items are highlighted.
Respiratory System
Ask about
1. Cough Dry or productive
2. Sputum Colour, amount, blood stained, time of the
day
3. Dyspnoea and its grades
4. Chest pain pertaining to respiratory problems
5. Fever
6. Wheezing.
Cardiovascular System
Ask about
1. Breathlessness at rest, on exertion or even on lying
down
HISTORY TAKING 17
2. Chest pain Site, duration, character, radiation,
relieving and aggravating factors
3. Palpitations
4. Cough
5. Abdominal pain (dissecting aortic aneurysm)
6. Oliguria
7. Oedema (swelling)
8. Syncope
9. Fever.
Gastrointestinal System
Ask about and Look for
1. Pain
2. Dyspepsia
3. Appetite
4. Vomiting
5. Odynophagia
6. Dysphagia
7. Flatulence
8. Jaundice
9. Water brash
10. Heart burn
11. Diarrhoea
12. Constipation
13. Malaena
14. Distension.
Urogenital System
Ask about
1. Dysuria
2. Polyuria, poor stream, feeling of incomplete evacuation
3. Frequency, urgency, hesitancy
4. Haematuria, post-micturition dribbling, urethral
discharge, strangury
5. Oliguria
6. Anuria
7. Puffiness of face
8. Lower abdominal pain
9. Fever with chills.
Haematological System
1. Pallor
2. Weakness
3. Lack of concentration
4. Dyspnoea
5. Ankle oedema
6. Easy bruisability
7. Skin lesions
8. Nose bleeding
9. Gum bleeding
10. Glandular enlargement
11. Bone pains
12. Fever with infections.
Central Nervous System (CNS)

Ask about and look for
1. Headache
2. Sleep disturbances
3. Vomiting
4. Visual disturbance
5. Altered sensorium
6. Convulsions
7. Dizziness
8. Speech, memory
9. Sense of smell, vision, hearing, gustation (taste)
10. Weakness, diplopia, twitching
HISTORY TAKING 19
11. Involuntary movements
12. Wasting
13. Stiffness
14. Bulk of muscles
15. Unsteadiness
16. Paraesthesia
17. Dysaesthesia
18. Anaesthesia
19. Difficulty in performing voluntary activities
20. Incontinence of urine or faeces
21. Urinary retention.
Nonspecific
1. Generalized weakness
2. Headaches
3. Fever Continuous, remittent to intermittent
4. Jaundice
5. Body pain
6. Generalized numbness
7. Generalized swelling of body
8. Weight loss
9. Giddiness
10. Sinking of heart.
Locomotor System
1. Pain
2. Swelling
3. Fever
4. Limitation of movements
5. Stiffness of joints with time and duration
6. Wasting
7. Contractures
8. Deformity
9. Limping.
Endocrine System
1. Weight loss or gain
2. Abnormal distribution of hair
3. Polydipsia
4. Craving for salt
5. Pigmentation
6. Striae
7. Headaches
8. Increased sweating
9. Blurring of vision
10. Vomiting
11. Increased/decreased libido
12. Hair loss
13. Voice changes
14. Frequency of shaving
15. Frontal baldness
16. Erectile dysfunction
17. Early morning erections/tumescence
18. Normal distributions of body hairs
19. Breast size, gynaecomastia in males
20. Heat or cold intolerance.
Dermatological System
Ask about and look for
1. Rashes
2. Macules
3. Papules
HISTORY TAKING 21
4. Pustules
5. Vesicles, bullae
6. Lumps and bumps
7. Pruritus
8. Sensitivities Drug and photosensitivity
9. Change in hair and nails
10. Ulcers
11. Bruises
12. Change in colour pigmentation/depigmentation.
Having asked a detailed history, and after detailed
systemic review and systemic examination you should be
able to present you history and findings to the examiner
in a coordinated smooth, fluent way, i.e. summarize the
case.
Sometimes you may encounter problems during history
taking. They are:
1. A depressed, confused or demented patient: You
should try your level best to elicit history but do not
waste time when you are getting nothing from the
patient. On the contrary, seek information from the
relatives or close friends.
2. Hostile patient: Sometimes one can encounter hostility
from a patient due to many reasons, e.g. depression,
confusion, agitation and other known to the patients.
However, you should stand by asking the reason of
hostility and take patient into confidence. If hostility
persists, then discontinue asking questions and take
help of staff nurse and/or immediate relative or close
friend of the patient.
3. Provocative patient: Sometimes patient is severely
provocative especially in the presence of female
assistant. Change over to a male chaperon. If not
available, then postpone the examination.
4. Less educated patient: Patient with low education level
or less vocabulary may cause difficulties in obtaining
a good history. Many nebulous terms are used in

medicine, i.e. numbness, sciatica, stroke etc. You have
to ask in more details from the patient to be sure what
actually he mean.
5. If a patient uses specific diagnosis for past history then
ask more details about it. Sometimes recall of all events
is difficult by the patient, therefore don not press hard
as it may offend the patients.
CHAPTER 23
INSTRUMENTS REQUIRED
4
Instruments
Required
As mentioned before, prior to clinical examination, you

should be well-equipped with all necessary gadgets for
examination purpose including from a small common pin
to a sphygmomanometer. I think that ideally the brief case
of the candidate should have the following items for a
more detailed and comprehensive examination:
1. Small Snellens chart 11. Thermometer

2. Sterile common pins 12. Disposable gloves
3. Cotton wool 13. Sphygmomanometer
4. Bottle of different odours 14. Callipers or two point
5. Tuning fork of freque- retractor
ncy of 128, 256 Hz 15. Goniometer
16. Paper cup
6. Patellar hammer
17. Tissue papers
7. Measuring tape
18. Bottles or test tubes for
8. Ophthalmoscope/Auro- hot/cold water
scope 19. Sugar, vinegar, salt,
9. Wooden spatulae quinine
10. Stethoscope 20. Coins, keys.
All these instruments/items should be placed in order
so that the candidate knows their whereabouts and at the
time of examination does not have to search here and there
thus wasting time unnecessarily when every second counts!
CHAPTER 25
GENERAL PHYSICAL EXAMINATION
5
General Physical
Examination
The physical examination is divided into:

A. General physical examination.
B. Systemic examination.
This includes:
1. Respiratory system
2. Cardiovascular system
3. Gastrointestinal system
4. Urogenital system
5. Nervous system
6. Musculoskeletal system or Locomotor system
7. Dermatological system.
PEARLS
The aim is to keep the patient comfortable, relaxed and
reassured. Let the patient know what you are going to
do, so that he is not apprehensive therefore ensuring full
cooperation from him. In cold weather a warm environment
and warm hands are essential. Privacy with natural light
is also desired.
It is advised to develop the art of routine performing
physical examination, routinely, which should be prompt,
accurate and less distressing to the patient. It is always
advised to plan examination according to patients main
or presenting symptoms.
It is important to know that one should be thorough
in performing different steps in clinical examination, of
which one becomes an expert with experience and one
gets more confident in looking directly for certain signs
suggested by history and examination. As you approach
the patient, re-establish both verbal and eye contact.
GENERAL PHYSICAL EXAMINATION 27
GENERAL INSTRUCTIONS FOR CONDUCTING

EXAMINATION
1. Use a couch which can be adjusted with a back rest.
2. To provide privacy, draw screens.
3. Make sure the light is natural and adequate.
4. Wash your hands prior to examination of the patient.
5. Stand on the right side of the patients couch.
6. Greet him and introduce yourself to him.
7. Ask permission for examination.
8. Explain the procedure and ask for his cooperation.
9. Warm the chest piece of stethoscope and your hand.
10. Undress the patient with his cooperation to a certain
reasonable modesty.
11. Examine both sides of the patient and compare the
findings.
12. Examine systematically i.e., first while the patient is
lying, then sitting and then standing. Do not ask the
patient to sit, lie down, sit again, stand, walk and
then lie down again.
13. Cover or dress the patient after the examination and
help him doing so if need be arise.
14. Thank the patient for his cooperation.
15. Wash your hands at the end of full examination or
a specific examination. It is better to wipe off with
tissue papers rather than blow dry.

Before doing the general physical examination you
should have a panoramic view of the patient and this
helps to make a rapid assessment of the severity of illness.
This of course does not help in diagnosis but can lead
to so many other points to recall in working for a diagnosis.
Even talking to the patient may reveal a number of

important points during the act of history taking. Simple
tasks like dressing, undressing, holding a glass of water
may reveal so many clues in clinching the ultimate
diagnosis. It is also important to note that some seriously
ill patients may not complain a lot and sometimes one
encounters an apparently healthy person who may have
serious underlying pathology.
It has been said that the experienced doctor begins the
examination on meeting the patient and continues taking the
history until the consultation ends.
Following steps are important to follow while
conducting a general physical examination:
Step by Step in General Physical Examination:
1. Stands on the right side of patient.
2. Greets, introduces himself to the patient and asks for
permission to examine.
3. Exposes the patient adequately observing the modesty.
4. Makes sure that the light is natural and adequate.
5. Checks for built, nutritional status by picking up skin
fat and noting its thickness and general look of the
patient.
6. While doing this, checks for the higher mental
functions by asking simple questions, i.e. name, date
of birth, address, time and recognition of people
around etc.
7. Does a panoramic view of the patient, i.e. patients
look as a whole.
8. Smells any unfamiliar odours coming from the patient
which may be of any of the followings:
Alcoholic smell
Acetone smell
Mousy smell
Halitosis (bad breath).
9. Examines the head for any abnormality and feels for

texture of hair. Moves his hand over the scalp for
evidence of tenderness, depressions (lumps and
bumps) and swellings.
10. Examines the eyes from front and sides with a torch
if necessary.
11. Pulls up the upper eyelid and asks the patient to look
down and looks for jaundice.
12. Pulls down the lower conjunctiva and asks the patient
to look up to see pallor, cyanosis or haemorrhages.
13. Turns up the tip of the nose with left thumb and
shines light from a torch holding that in right hand
to see inside the nose and notes down any abnor-
mality.
14. Presses over the paranasal sinuses, i.e. maxillary,
frontal and ethmoidal sinuses with the tip of right
thumb to elicit any tenderness.
15. Looks for any abnormality of the pinna or nodules
(tophi) or any vesicles or discharge by shining light
in the ear.
16. Looks at the cheeks for buccal pad of fat or any
erythema or rash.
17. Looks at the lips.
18. Looks into the mouth with the help of a torch and
a wooden tongue depressor with proper instructions
to the patient (described later).
19. Looks carefully at the gums, teeth and tongue and
notes down any abnormalities.
20. Looks into the throat for especially examining tonsils
and posterior pharyngeal wall and the uvula,
movement of soft palate.
21. Inspects the neck from the front and sides.
22. Asks the patient to swallow and observes the
movement of the larynx.
23. Palpates the neck for thyroid swelling or cervical

lymph nodes.
24. Examines the hands from palmar and dorsal aspect.
25. Looks at nails for clubbing, pallor, cyanosis,
koilonychia, colour, splinter haemorrhages.
26. Looks at the palmar aspect of hand for any erythema/
pallor/pigmented creases or Dupuytrens contrac-
tures.
27. Feels the radial pulse either for one minute (or 15
seconds then multiply by 4), compares both radial
pulses, checks for radio femoral delay.
28. Checks blood pressure in supine position.
29. Records any vital signs i.e. pulse, temperature and
respiration in the initial stage of examination.
30. Checks the axillary lymph nodes and checks blood
pressure in sitting position if indicated.
31. Briefly looks at chest for any deformity and abdomen
for any distension.
32. Feels for any inguinal lymph nodes if present.
33. Checks oedema in the lower limbs by pressing the
leg above the medial malleolus.
34. Checks the dorsalis pedis artery for pulsations.
35. Examines the skin as a whole and looks for any
abnormal pigmentation, depigmentation, skin
eruptions and subcutaneous emphysema.
36. Looks for any abnormal deformities of bones and
joints.
37. Rechecks blood pressure when patient stands to note
any orthostatic hypotension.
38. Observes the gait if patient is able to walk (It is best
observed when patient walks into the consultation
room).
39. Asks the patient to re-dress and provides help if
necessary.
40. Thanks the patient at the end of the examination for

his cooperation.
This seems a very lengthy process but actually it should
take hardly 5-7 minutes if one has done practice and if
one knows that what one is trying to look for. Therefore,
it should not seem difficult at all.
CASE WRITING TIPS

It is better to start from head, face, neck, hand, upper limbs,
axillae, chest, abdomen, lower limbs, back (sitting up),
standing up and then to look for gait.
1. General appearance
2. Head
3. Hair
4. Eyes
5. Face
6. Mouth
7. Pharynx
8. Neck
9. Hands
10. Upper limbs
11. Axillae
12. Thorax
13. Abdomen
14. Lower limbs
15. Spine
16. Gait.
STEP BY STEP EXAMINATION OF THE PATIENT

AS A WHOLE
This section is written for the convenience of the candidate
in which the examination of the patient is described from
step one to the last step including salient examination
skills of all the important systems briefly including the
general physical examination. The candidate is advised
to master this schema as much as possible as it will act
as a skeleton or frame work when he performs
individual systemic examination. For more detailed
systemic examination skills the candidate is advised to
go through the section on individual systems.
The Candidate
1. Stands on the right side of the bed of the patient.
3. Exposes the patient adequately and makes sure the
light is adequate, modesty should be observed.
4. While doing this, checks for higher mental functions
by asking questions as name, date of birth, address,
recognition of people around etc.
5. Does a general survey (panoramic view) of the patient
while exposing.
6. Examines the head and feels for the texture of hair.
7. Examines the eyes from front and sides with a torch
if necessary.
8. Examines the oral cavity with the help of a torch and
tongue depressor with proper instructions to the
patient.
9. Inspects the neck from front and sides, asks the patient
to swallow and observes, palpates for the cervical
lymph nodes and thyroid.
10. Examines hands from palmar and dorsal aspects and
looks at nails.
11. Feels for the radial pulse, compares both, checks for
radio-femoral delay and measures blood pressure in
supine position.
12. Inspects the chest and abdomen from front and sides,
looks at the apex beat with his eyes at the level of
the chest and from the foot end of bed and counts
for the respiratory rate.
13. Palpates for trachea, sternum, left para-sternal area.
14. Localizes apex beat and turns the patient to the left
if necessary.
15. Checks movements of the chest and vocal fremitus
anteriorly.
16. Percusses the chest above, over and below clavicles
and for cardiac dullness and upper border of the liver.
17. Auscultates for breath sounds and vocal resonance,
auscultates heart sounds at the base, parasternal area,
epigastrium and mitral area.
18. Auscultates mitral area with diaphragm and bell of
the stethoscope in supine position while palpating
the carotids simultaneously. Auscultates adjacent
area towards axilla for radiation if indicated.
19. Turns the patient to the left side and clearly instructs
him on how to hold his breath in complete expiration.
20. Auscultates mitral area with bell of the stethoscope
in this position with breath held in expiration.
21. Asks the patient to resume breathing immediately
afterwards.
22. Auscultates tricuspid area with diaphragm and bell
in supine position and notes the effects of respiration.
23. Auscultates pulmonary and both aortic areas with
diaphragm, in supine position and notes the effects
of respiration.
24. Auscultates over carotids and left sternal border
while instructing the patient to hold his breath.
25. Auscultates over other areas if indicated (for any

radiation).
26. While palpating abdomen makes sure the hands are
warm.
27. Asks the patient to relax and makes him in a
comfortable position, with legs slightly flexed.
28. Asks about any tender area in the abdomen.
29. Performs light palpation in an S shaped manner.
30. Palpates the liver from right iliac fossa upwards.
31. Palpates the kidneys bimanually and elicits any
ballottement.
32. Palpates the spleen first in the supine position starting
from right iliac fossa across to left hypochondrium
while asking the patient to breath deeply. If the spleen
is not palpable then:
33. Palpates the spleen by turning the patient to the right
lateral position supporting the back of the left chest
by the left hand with light compression anteriorly
and using right hand to feel the spleen in deep
inspiration. If the spleen is still not palpable then:
34. Palpates the spleen in the above mentioned position
but with the left arm of the patient under his head.
35. Palpates with dipping method if there is tense ascites.
36. Percusses the liver and splenic dullness and measures
the liver and splenic span in centimetres.
37. Percusses for shifting dullness and elicits fluid thrill
if the shifting dullness is positive.
38. Auscultates bowl sounds for at least 30 seconds and
listens for any visceral bruits. If bowel sounds are
absent, listens for 3 minutes.
39. Demonstrates succussion splash if appropriate.
40. Raises the head against resistance while looking at
abdomen for any divarication of recti and any
appearance or disappearance of abdominal masses.
41. Checks for springing of sacroiliac joints.

42. Examines the upper limbs for bulk of the muscles
and abnormal movements.
43. Assesses the tone of the muscles of upper limbs.
44. Assesses the power of the muscles of upper limbs
actively and passively.
45. Checks the biceps, triceps and supinator jerks.
46. Checks for coordination of movements by performing
finger nose test or tapping of the palms.
47. Checks for superficial and deep sensations in the
upper limbs.
48. Examines the legs and feels for calf tenderness,
dorsalis paedis, and posterior tibial pulses.
49. Inspects the feet and notes for any poedal oedema.
50. Inspects the bulk of muscles and any abnormal
movements in the lower limbs.
51. Assesses the tone of the muscles of lower limbs.
52. Assesses the power of muscles of lower limbs actively
and passively.
53. Checks for knee jerk, ankle jerk and plantar responses.
54. Checks for coordination of movements in the lower
limbs by performing heel shin test.
lower limbs.
56. Checks for signs of meningeal irritation.
57. Makes the patient sit up at 45 and examines the
jugular venous pressure (JVP).
58. Makes the patient sit up at right angle and examines
the chest from the back, looks for any spinal deformity
and elicits spinal tenderness and sacral oedema.
59. Checks the blood pressure if indicated in this position.
60. Checks for the cranial nerves.
61. Makes the patient stand, asks him to cough and looks
for hernial orifices.
62. Checks the blood pressure if required in this position.
63. Measures height and weight if desired.

64. Performs heel-occiput and Schobers test, Rombergs
test if indicated, after taking permission from patient
and examiner.
65. Asks the patient to walk on a straight line to see the
gait (Tendem walking).
66. Performs fundoscopy, rectal and pelvic examination
if required but with the permission of the examiner.
67. Thanks the patient for his cooperation and asks him
to dress up and helps him if necessary.

Common Commands Asked during Examination
1. Assess the nourishment or nutritional status
2. Look for pallor
3. Look for cyanosis
4. Look for jaundice
5. Look for clubbing
6. Palpate lymph nodes in the neck
7. Check for peripheral oedema
8. Check arterial pulses
9. Check for radial pulse
10. Check the blood pressure
11. Check the temperature
12. Look at this patients face
13. Examine the thyroid gland
14. Examine the breasts
15. Examine the oropharynx (throat)
16. Examine the tongue.
GENERAL PHYSICAL EXAMINATION COMMANDS

Assess the Nutritional Status of the Patient
The Candidate
1. Stands on the right side of patient
2. Greets, introduces himself to the patient and asks
permission for examination.
3. Exposes the patient adequately, observing the
modesty.
4. Makes sure the light is adequate and natural.
5. Does a general survey of the patient.
6. Does anthropometric measurements.
7. Notes the distribution of fat.
8. Notes the weight and height of the patient.
9. Checks for wasting of muscles e.g. sunken eyes,
temporal wasting, facial wasting and small muscle
of hands.
10. Examines skin for dryness and cracks.
11. Feels texture of hair.
12. Checks for subcutaneous fat at biceps, triceps and
suprailiac regions.
13. Picks up the skin and fat and notices its thickness,
uses callipers if well versed with using them.
14. Looks at angle of mouth and tongue for any
nutritional deficiency status.
15. Helps the patient redressing.
16. Thanks the patient for his cooperation.
17. Notes down all the findings and comments while
presenting his case to the examiner.
PEARLS
a. The candidate should know the definition of the terms
like metabolic rate, BMI, caloric value of fats, sugars
and proteins.
b. The candidate should know a checklist of causes of
wasting or cachexia.
c. He should also know the normal waist circumference
in males and females and types of obesity. He should
know waist-to-hip ratio in both males and females.
Look for Pallor

The Candidate
modesty.
6. Everts both lower eyelids.
7. Asks the patient to look upwards.
8. Asks the patient to open the mouth and looks under
the tongue and angles of the mouth.
9. Examines the palms for pallor of creases as well (see
below) and compares with his own palms.
10. Helps the patient re-dressing if necessary.
12. Finally, comments on presence or absence of pallor
while presenting his case to the examiner.
PEARLS
a. The candidate should know important causes of pallor
in the form of a check list. The candidate should know
the difference between pallor and anaemia. Pallor is
clinical assessment of degree of anaemia. Anaemia is
a laboratory finding.
b. Normally the creases are pinker than the palm and
Hb is estimated to be 12-14 g/dl. If the palm is pale
but creases are pink then approximate Hb is around
10 g/dl. If the creases are also pale then the Hb is
< 8 g/dl. Anaemia is one of the causes of pallor.
Look for Cyanosis

The Candidate
modesty.
6. Examines the lips, tongue and oral mucosa.
7. Examines the cheeks, ear lobes and tip of the nose.
8. Examines the hands and nail beds for any bluish
discolouration.
9. Comments on the type of cyanosis, i.e. whether
peripheral or central.
10. If in doubt asks the patient to exert for a couple of
minutes. (This will make central cyanosis more
prominent).
11. Helps the patient re-dressing.
13. Finally comments on presence or absence of cyanosis
and its type while presenting his case to the examiner.
PEARLS
The candidate should know the types of cyanosis, their
causes and the differences between various types.
Look for Clubbing

The Candidate
modesty.
6. Examines the finger nails at a tangent bringing his
eyes at the same level to see the angle between nail
fold and the nail plate called Lovibond angle.
7. Brings nails of the fingers or thumbs of both hands
together and opposes their dorsal surfaces,
(Schamroth sign) and looks for the space between
the two nails.
8. Holds the nail bed with thumbs and tips of his index
fingers of his both hands.
9. Palpates the nail bed to elicit fluctuation.
10. Looks for clubbing in all the fingers and toes and
does its grading (see below).
11. Compares the findings in hands with those in the
toes.
12. Looks for widening and tenderness of the ends of
long bones for evidence of hypertrophic osteo-
arthropathy.
15. Comments whether clubbing is present or absent and
if present tells the grading of clubbing.
PEARLS
Grading of clubbing
They are divided in four grades.
Grade 1: Fluctuation at the bed of nail
Grade 2: Obliteration or increase in the angle between
nails bed and nail plate.
Grade 3: Beaking of the nail.
Grade 4: Drum-stick appearance.
a. You should be aware of the causes of clubbing and
types of clubbing.
b. If the examiner asks you Which single question would
you ask from this patient to know the cause of
clubbing? You should ask from the patient. Is this
abnormality present since childhood? This will rule
out or rule in the congenital causes of clubbing.
Therefore the things may get easier.
c. You can see the angle by putting a paper vertically
on the nail plate and nail bed. A space will be seen
if angle is not obliterated.
Look for Jaundice

The Candidate
1. Stands on the right side of the patient.
modesty.( if wearing a veil)
6. Lifts the upper eyelids and asks the patient to look
down.
7. Examines the soft palate, and under surface of the
tongue.
8. Examines the palms and the skin.

11. Comments on presence or absence of jaundice and
its severity.
PEARLS
a. Sclera and soft palate become yellow earlier than skin.
Severe jaundice is present if all the sites are stained.
b. Bilirubin has an affinity for elastic tissue which is
composed of elastin, and it is abundant in sclera,
therefore the earliest and best site to look for jaundice.
c. Lemon yellow colour indicates mild jaundice, orange
yellow indicates moderate jaundice and greenish
yellow indicates severe jaundice. They also indicate
the underlying cause, i.e. haemolytic, hepato-cellular
and obstructive jaundice respectively.
Check for Lymphadenopathy

The Candidate
modesty.
6. Makes the patient sit comfortably.
7. Notes any sinuses opening on to the skin or
cicatrization or scarring of the skin.
8. Flexes the patients neck forward.
9. Approaches the patient from behind the neck.
10. Flexes the neck on the side of examination. (either
right or left).
11. Palpates the lymph nodes on that side by pushing

the fingers from above downwards.
12. Examines all the groups of lymph nodes systemati-
cally i.e., submental, submandibular, jugulo-digastric,
pre-auricular, post-auricular and occipital lymph
nodes.
13. Palpates especially for scalene lymph node (see
pearls)
14. Examines both sides of the neck.
17. Comments on the location, size, tenderness, texture
and degree of fixation to the skin above.
Check Lymph Nodes in Axilla

The Candidate
modesty.
6. Makes the patient sit up on a chair.
7. Approaches from front of the patient.
8. Abducts patients left arm and rests patients fore arm
over his (candidate) left arm.
9. Inserts his right hand in patients left axilla and feels
the apex and medial wall by sliding movements of
the fingers.
10. Places patients left arm over his (candidate) right
arm, and feels the lateral wall of the left axilla by
his left (candidate) hand.
11. Abducts patients right arm and rests patients right

pre free arm over his (candidate) right arm and insert
his left hand in right axilla and feels the apex and
medial wall by sliding movements of the fingers.
12. Places patients right-arm over his left arm and inserts
right hand, palm facing laterally in patients right
axilla to feel the lateral wall of right-axilla.
13. Palpates the anterior axillary fold between the fingers
and the thumb.
14. Goes behind the patient and palpates the posterior
axillary folds.
17. Comments on the size, tenderness, texture and degree
of fixation of the lymph nodes while presenting to
the examiner.
Check Lymph Nodes in the Inguinal Region

The Candidate
modesty.
6. Makes the patient lie supine
7. Asks the patient to flex the opposite thigh.
8. Palpates above and below the inguinal ligament.
9. Examines on the both sides and compares the
findings.
12. Comments on the findings while presenting to the

examiner.
PEARLS
a. Complete relaxation of the part to be examined is
important for palpation of even smaller lymph nodes.
b. Movements should be slow and gentle in rotatory
manner.
c. In normal subjects, only few inguinal lymph nodes are
usually palpable.
d. Sometimes the examiner asks about the external and
internal rings of Waldayer, and the candidate should
know its location and components of both these rings.
The external ring is composed of submental, sub-
mandibular, jugulodigastric, pre-auricular, post-
auricular and occipital lymph nodes, where as the
internal ring is composed of lingual tonsils, palatine
tonsils, tubal tonsils and the adenoids.
e. The scalene lymph node is present deeply between the
sternal and clavicular head of sternocleidomastoid
muscle. The patients neck is slightly flexed and rotated
to the opposite side (towards left). The examiner puts
tip of his right index finger facing downwards and
medially towards apex of the heart and asks the patient
to take a deep breath in. The lymph node if enlarged,
can be felt as a firm object touching the pulp of finger.
Scalene lymph node is palpable in case of carcinoma
bronchus.
Look for Peripheral Oedema

The Candidate

modesty.
6. Uses thumb for exerting pressure.
7. Applies pressure for 5-30 seconds over the part
of leg behind medial malleolus or lower part of the
shin.
8. Looks for any pitting and feels it with his finger for
a well or a dimple.
9. Does same manoeuvre over the sacrum.
10. Examines abdominal wall for oedema.
11. Makes sure to examine both sides.
14. Comments whether pitting or nonpitting oedema,
unilateral or bilateral and the side of oedema.
PEARLS
If the dimple or pitting caused by pressure fills up with
in 30-40 seconds it is called fast oedema but if it takes more
than 40 seconds, it is called slow oedema. In the former
case, hypo-albuminaemia and in the later case cardiac
oedema can be quoted as examples.
CHECK PERIPHERAL PULSES

Check for Radial Pulse
The Candidate

modesty.
6. Semi pronates the fore arm of the patient keeping it
by his side.
7. Flexes the wrist slightly.
8. Uses the distal parts of the three fingers (index, ring
and middle) of his right hand to compress the vessel
against lower end of radius.
9. Examines the femoral pulse simultaneously with his
left hand and checks for any radiofemoral delay.
10. Counts for at least 15-30 seconds.
13. Comments on rate, rhythm, volume, character, and
consistency of vessel wall while presenting to the
examiner.
PEARLS
a. Check for pulse deficit if the pulse is irregularly
irregular. The candidate should know how to examine
other pulses i.e., brachial, axillary, superficial temporal,
femoral, popliteal, posterior tibial and dorsalis pedis
arteries.
b. To know the condition of the vessel wall, roll the vessel
wall against a hard area i.e., lower end of radius to
feel the consistency of vessel wall.
Check the Carotid Pulse
The Candidate

modesty.
6. Asks the patient to look straight ahead.
7. Exerts slight pressure with his left thumb on the mid
cervical region backwards at the level of sterno-
mastoid muscle and lateral to the thyroid cartilage.
8. Counts for at least one minute.
9. Does not palpate both carotids simultaneously (see
pearls).
examiner.
PEARLS
a. Never palpate both carotids simultaneously as it can
stimulate carotid body leading in turn to para-
sympathetic stimulation. This causes severe
bradycardia leading to hypotension and patient may
collapse.
b. The character of pulse is best felt in the carotids or
brachial artery as they are more close to the aorta.
Axillary artery is technically difficult to palpate.
c. The candidate should know different characters of the
pulse i.e., anacrotic pulse, bisferiens, jerky pulse,
dicrotic pulse, collapsing pulse and pulsus paradoxus.
Check Collapsing (water hammer) Pulse

The Candidate
1. Stands on the right side of the patient
modesty.
6. Asks the patient if he has any painful condition of
the shoulder on the same side.
7. Pronates patients forearm fully.
8. Places palm of the right hand on the radial pulse.
9. Supports the patients elbow with his left hand after
straightening patients arm.
10. Raises the patients arm above the level of his head
briskly.
11. Feels the thrust of the radial pulse over the palm
around the wrist.
14. Comments on its presence or absence while presenting
to the examiner.
PEARLS
Candidate should know causes of collapsing pulse.
Check Pulsus Paradoxus

The candidate:
1. Stands on the right side of the patient

modesty.
6. Feels the pulse at brachial artery.
7. Applies the cuff of the sphygmomanometer over the
upper forearm.
8. Inflates the cuff above systolic pressure.
9. Asks the patient to take deep breaths throughout.
10. Places the diaphragm of his stethoscope over the
brachial artery.
11. Lowers the mercury column slowly by deflating the
cuff.
12. Notes the level of mercury at which Korotkoffs sound
are heard only during expiration.
13. Notes the level of mercury at which the sounds are
heard during inspiration.
14. Notes the difference between these two levels.
examiner.
PEARLS
a. Pulsus paradoxus is said to be present if the difference
in the level of mercury is more than 10 mm.
b. Another method is to palpate the pulse, which may
not be palpable during inspiration but becomes
palpable during expiration.
Check the Blood Pressure
The Candidate
3. Exposes the patient adequately, observing the modesty.

6. Patient is either sitting or lying in the bed.
7. Ensures he is under basal conditions i.e., not
distressed, has not smoked recently or has not had
a recent meal.
8. Ensures that the patients arm is at patients heart
level.
9. Places the sphygmomanometer at the side of patient
at the level of his eyes. The candidates eyes should
also be at level of mercury in the sphygmomanometer.
10. Applies the appropriate sized cuff over the upper
limb.
11. Makes sure that the lower border of the cuff is about
2.5-5.0 cm above the cubital fossa and 2.5 cm below
the axilla. The rubber tubing should be in line with
the brachial artery.
12. Inflates the cuff with the bulb.
13. Determines systolic pressure by palpation.
14. Raises the pressure in the cuff to about 30-40 mm
of the systolic pressure. (which is already known with
the palpatory method)
15. Brings back the level of sphygmomanometer to zero
before inflating the cuff.
16. Places the diaphragm of the stethoscope lightly over
the brachial artery.
17. Deflates slowly the bladder so that the column of
mercury drops at a rate of 3-5 mm per second.
18. Records the pressure when the sounds appear.
19. Keeps deflating and records pressure when sounds
become muffled or disappear.
20. Records BP in all the limbs if indicated in examination
of that particular case.
21. Checks the blood pressure in supine and standing

positions to check for postural hypotension.
examiner.
PEARLS
a. If pulse is irregular then take at least three readings
and get an average.
b. In palpatory method, systolic blood pressure is when
the pulse is felt. Keep on deflating the bladder, until
the pulse from bounding quality comes to a normal
quality. This level is approximately diastolic pressure.
c. Application of cuff should not be loose.
d. Cuff should be at the same level as of the heart.
Check Blood Pressure in Lower Limbs
The Candidate
modesty.
6. Uses larger cuff for this purpose.
7. Makes the patient lie prone.
8. Palpates popliteal artery.
9. Applies the cuff at mid thigh with tubings in the line
with the popliteal artery.
10. Places diaphragm of stethoscope over popliteal artery

(as over brachial artery in the upper limb).
11. Inflates and deflates and notes the readings.
examiner.
If Large Cuff is Unavailable

The Candidate
modesty.
6. Asks the patient to lie supine.
7. Applies the cuff (ordinary size) at the middle of the
calf.
8. Palpates posterior tibial artery or dorsalis paedis
artery.
9. Inflates and deflates the cuff and listens over the
posterior tibial or dorsalis paedis arteries.
10. Notes down the readings.
12. Thanks the patient for his co-operation.
examiner.
PEARLS
Krotokoffs sounds
They are five in number and represent various degrees
of intensity of the heart sounds.
Tapping sounds
Like a bruit (hissing)
Loud sharp sounds
Muffled sounds
No sounds (disappear).
4th phase is the one which is recorded more precisely.
a. Normal BP is 100-140/60-80 mm of Hg.
b. Systolic BP in the right upper limb is 10 mmHg more
than the left.
c. Systolic BP in the lower limbs is usually not more than
20mm of Hg and the diastolic BP is not more than
10mm Hg than the upper limbs.
d. Record BP form non paralyzed side if the patient has
hemiplegia.
Check Temperature
The Candidate
modesty.
6. Uses a sterile thermometer if possible.
7. Looks at its level, shakes it down, and looks at it
again to see the mercury level is below the normal
temperature mark.
8. Explains to the patient what is he going to do.
9. Makes sure that the patient has not had any thing
hot either liquid or solid.
10. Asks the patient to open the mouth and lift the tongue
up.
11. Puts the bulb of thermometer on the side of fraenulum

linguae.
12. Asks the patient to lower the tongue and close the
mouth but keep the lips closed and warns not to bite
the thermometer with teeth and instructs to breath
through nose.
13. Keeps the thermometer at least for one minute.
14. Asks the patient not to rub the tongue against the
bulb of the thermometer while in the mouth.
15. Takes the readings immediately.
examiner.
PEARLS
a. During routine examination insert the oral thermometer;
count the radial pulse and respiration rate. This saves
time and you get all the three readings in one minute
rather than spending one minute each on these vital
signs. This is more important when the candidate is
asked to see a short case with general physical
examination when the time is also very short!
b. Avoid axillae or groins as far as possible for recording
temperature. The reading may not be accurate.
c. Reader should be aware of the types of fever i.e.,
continuous, intermittent, remittent and quotidian,
quartan and tertian fever, Pel-Epstein fever and
undulant fever, etc.
Examine the Thyroid

The Candidate
3. Exposes the patient adequately, observing the modesty

(if the patient is a female and is wearing a veil)
6. Looks at the neck from the front and the sides.
7. Asks the patient to put some water in the mouth but
to keep it there till asked further.
8. Asks the patient to swallow that water which was
kept in his mouth.
9. Looks for movement of any swelling in front of the
neck while swallowing that water.
10. Asks to protrude the tongue and observes any
movements of the swelling in front of the neck.
11. Stands behind the patient.
12. Flexes the neck slightly forwards.
13. Feels for any swelling with his fingers of both hands
by putting thumbs over the patients occiput.
14. Feels the isthmus first in the midline over tracheal
rings.
15. Flexes and rotates the neck towards the side of
palpation. Pushes the larynx to the same side and
with the other hand palpates the lobe of thyroid on
both sides.
16. Notes the position of the trachea as well.
17. Percusses the suprasternal area for any retrosternal
extension.
18. Listens for any bruit over the isthmus and lobes of
thyroid by lightly pressing the diaphragm of the
stethoscope and asking the patient to hold breath for
a while.
19. Looks for any relevant signs i.e., carotid pulsation,
Horners syndrome, tremors of the out stretched hands
and eye signs.
20. Help the patient re-dressing (if wearing the veil).

22. Comments on the findings and a probable diagnosis
while presenting to the examiner.
PEARLS
a. Fine tremors are more obvious if a piece of paper is
placed over the out stretched hands avoiding any
draught of air.
b. Look at the side of face and over the forehead from
the back at a tangent for exophthalmos.
c. Feel palms for warm sweat (cold sweat is felt in anxiety)
d. Feel pulse for tachycardia.
e. Feel for the carotid pulse which is not palpable in
malignant swellings of thyroid where as it is palpable
but displaced laterally in simple goitres whatever is
their size.
f. Pembertons sign: Ask the patient to raise both arms and
bring closer to the ears until their medial sides touch
both his ears. Hold up for sometime and look for
congestion of the face, cyanosis and distress which
occur in a retro-sternal goitre.
g. Kochers test: Press the lateral lobes of thyroid and note
for any stridor which occurs due to compressed
trachea.
Examine the Breasts

This is an important aspect of clinical examination in view
of the increasing incidence of breast cancers in females.
It is also important to have a female chaperon while
examining breasts of a female patient.
The Candidate
modesty.
6. Makes the patient sit on a chair in front of himself.
7. Looks for bumps in the breasts, axillae, flattening of
breasts and any skin dimpling.
8. Looks for asymmetry of nipple any discharge and
areola for any abnormality.
9. Asks the patient to place her hands at either side of
her hips or over her thighs.
10. Asks the patient to press her hips with her hands
already placed over them. Looks for any asymmetry.
11. Asks the patient to raise the hands and place both
palms of the hands behind her head and press
forwards. Looks for any asymmetry.
12. Asks the patient to lean forward.
13. Observes for any asymmetry of the nipples and
oedema of the arm.
14. Makes the patient lie down on the couch with a pillow
below her chest and the arm under the head on the
side of examination.
15. Palpates the breast with the palm of his hand rolling
over the breast against chest wall in all four
quadrants.
16. Feels for any masses or ulcers and notes its size, shape,
tenderness, mobility, overlying skin and discharge
from the nipple.
17. Palpates the normal breast first.
18. Palpates the areola and express any discharge from
the nipple.
19. Palpates the corresponding axilla, supraclavicular

area and scalene area for any lymphadenopathy.
22. Comments on the findings and a probable diagnosis
while presenting to the examiner.
PEARLS
a. Follow the technique of palpating upper inner quadrant
then lower inner, then lower outer and then upper outer
quadrant. Examination finishes after palpating axilla
on the same side.
b. Expression of the nipple can be done in medio-lateral
direction or supero-inferior direction.
c. Normal breast tissue is nodular and can be engorged
premenstrually.
d. In doubtful cases the examination is repeated at
different time of the menstrual cycle.
e. Any definite lump in breast should be palpated bi-
manually.
f. General examination is not complete, unless the breasts
(both) are examined. In our set up due to social reasons,
this examination is commonly omitted or missed
completely which should not happen as a routine.
g. Breast is examined in many positions to detect early
changes.
By sitting up the patient and hands on thighs
causing relaxation of pectorales muscles.
By pressing hands on hips causing contraction of
pectorales muscle.
By raising the arms above the head and both palms
placed behind head causing the breast, to be
stretched along with the skin.
By leaning the patient forwards causing breasts to
become pendulous.
By making patient lie down with the same arm

behind the head and putting a pillow underneath
the shoulder blade causing the breast more
prominent.
Examine the Patients Throat

The Candidate
(in case the patient is wearing a veil)
6. Asks the patient whether he had eaten any meals
recently. If so how recently?
7. Asks the assistant to hold the head.
8. Asks the patient to open the mouth and advises him
to keep the tongue inside and relax. Looks at lips
for ulcers or telangiectasias and also looks at the
gums, teeth and inner sides of the cheeks.
9. Holds a wooden tongue depressor in his left hand
and depresses the tongue at its posterior 1/3 and
middle 1/3.
10. Shines the light held in his right hand.
11. Touches the tonsillar pillars to elicit a gag reflex.
12. Looks at the posterior pharyngeal wall.
14. Comments on the findings of his examination while
presenting to the examiner.
PEARLS
a. The question of recent meals is important to ask as
if the patient has had a meal recently and during
examination of throat, the gag reflex is stimulated,
patient may vomit instantly on to the examiner.
b. It is very important to ask the patient to keep his tongue
in the mouth as it does not obstruct the view of the
throat because it is relaxed while in the mouth.
Examine the Patients Tongue

The Candidate
modesty.(in case the patient is wearing a veil)
6. Asks the patient to open the mouth and keep the
tongue in side.
7. Looks for colour, moistness, furring and surface of
the tongue.
8. Looks for any asymmetry or fibrillation of the tongue.
9. Asks the patient to protrude the tongue and looks
for any evidence of deviation, ankylosis in case of
tongue-tie or atrophy of the tongue.
10. Asks the patient to touch his palate with the tip of
his tongue, and looks under the surface of the tongue,
fraenulum linguae or for any telangiectasias and the
floor of the mouth.
11. Looks for ulcers (if so then feels for the induration
underneath), leukoplakia, nodules or blackening of
the tongue.
12. Asks the patient to wiggle the tongue on the inner

side of each cheek and pushes it in opposite directions
from outside to see the strength of the tongue.
14. Comments on the findings of this examination while
PEARLS
a. The candidate should be aware of various types of
tongues in medicine i.e., normal, black hairy,
fissured, beefy, macroglossia, geographical tongue,
scrotal tongue, bald tongue, candidiasis, leukoplakia,
strawberry tongue, mucosal neuromas, aphthous
ulcers, lichen planus and coated tongue and many
others.
b. Some time it is important to hold the tip of the tongue
with a gauze piece and thoroughly examine it.
c. If any neurological deficit is suspected then check the
sense of taste as follows:
Wipe the tongue to make it dry.
Instruction to the patient is very important. Ask him
to raise index finger if sweet, middle finger if saltish,
and little finger if bitter taste is felt.
Put a drop of solution on both halves of the tongue
separately.
Ask the patient to raise the respective finger when
he feels the taste.
d. Palpation makes an important part of the examination
of the tongue. Following steps are important to follow:
Put on a disposable pair of gloves.
Ask the patient to remove any dentures.
Ask the patient to elevate the tongue and move to
one side.
Place the index finger of right hand beneath the

tongue on one side of fraenulum of the tongue and
run the finger back on the floor of mouth. Run the
finger on the lateral side of tongue and then over
the same half on the dorsum and then towards the
buccal side of the gums up to the mucosa of
ascending ramus and then examine both buccal and
palatal aspects of the teeth of the upper jaw.
e. For bimanual examination:
Place the right index finger in the floor of the mouth
and press with the fingertips of left hand beneath
the mandible and exert little pressure in between
these two.
Sometimes one has to hold the tongue with a gauze
piece between fingers and thumb of the other hand
and palpate the tongue with right index and thumb.
Palpation of posterior 1/3 of tongue is difficult as
it can cause gag reflex and patient may vomit.
CHAPTER 6
Examination of
Respiratory
System
This system is discussed under four headings as follows:

1. Principles of examination of respiratory system
2. Examination of the respiratory system as a whole (for
long cases)
3. Schematic out line of respiratory system
4. Common commands in respiratory system (for short
cases)
PRINCIPLES OF EXAMINATION OF RESPIRATORY

SYSTEM
Before starting, one should know briefly the surface
markings of the lungs in particular relation with the ribs,
sternum and scapulae and certain principles of the
examination of respiratory system. These principles
include inspection, palpation, percussion and auscultation.
Principles of Inspection
The patient should be undressed to the waist and in case
of females, modesty should be observed and breasts should
be covered properly. However, the patient should be
explained the need of proper exposure.
The patient may be lying on the couch at 45 or should
be seated on the bed with legs hanging over the side. The
examiner stands back and looks at the front, side and back
of the chest for any abnormality, structurally or
functionally i.e., shape, symmetry, scars, kypho-scoliosis,
barrel chest, prominent veins, respiratory movements,
dyspnoea etc, or pattern of breathing i.e., Cheyne stokes
and Kussmauls breathing. The examiner should also
listen for any abnormal audible sounds coming from the
chest i.e., noises, wheezing, stridor or hoarseness if the
patient speaks. The examiner should also inspect the
movements of the chest with respiration and abnormalities
EXAMINATION OF RESPIRATORY SYSTEM 67
of the supra sternal notch in the form of asymmetrical

filling indicating mediastinal shifting.
One should look for clubbing and cyanosis, tar staining
of the fingers and nails and pallor of the hands. Also check
for wasting of muscles and elicit asterixis or metabolic
tremors. Wrists should be palpated for any bony tenderness
(hypertrophic pulmonary osteo-arthropathy). Look at the
face for ptosis and constricted pupil, swelling of face and
suffusion of the face, fullness of supra clavicular fossae
for superior vena caval (SVC) obstruction along with
dilated veins in front of the chest. If there is a fresh sample
of sputum, then it should be examined for colour,
consistency, froth and quantity.
Principles of Palpation
The position of trachea should be palpated first either by
one finger or three fingers method. Try to insert finger
between medial borders of each sternomastoid muscles
and feel any resistance. The trachea is then deviated to
the site of resistance. Just slide index finger forward over
the supra sternal notch and if it touches a firm object, then
the trachea is central. The other method is the three-finger
method where index and ring fingers are placed on both
sternoclavicular joints and the middle finger is used to
palpate trachea.
Feel for the tracheal tug which is done by putting index,
middle and ring finger vertically above the supra-sternal
notch and patient is asked to breathe in, the cricoid
cartilage along with trachea moves downward during
inspiration. (presence indicates pulmonary fibrosis)
Supraclavicular lymph nodes should be palpated for
their presence and fullness of the fossae. Palpate also for
scalene lymph node (described later). Now palpate for the
movements of the chest wall by gripping the sides with

fingers of both hands as far back as possible and bring
the thumbs in the midline but keep the thumbs off the
chest wall. Movements of the chest cause movement of
the thumbs away from the midline. At apex, there is up
and down movements, at mammary areas the movement
is in horizontal direction and in the intra-scapular area
the movement is again in the horizontal direction.
Vocal fremitus is palpated with either palm or ulnar
border of palm alternately on right and left side and by
asking the patient to say 99 or 123 repeatedly. Check
for inter-costal tenderness by pressing with thumb and
look at the patients face for any pain when he winces.
Palpate also for any subcutaneous emphysema.
Principles of Percussion
It requires considerable practice and in turn indicates how
much time a student has spent in the wards. The
percussion should start from a resonant to dull area so
as to easily appreciate the change. The left middle finger
is used as pleximeter finger and the tip of the right middle
finger as plexor (vice versa if one is left handed!).
The movement should be at wrist joint rather than at
the elbow. Pleximeter should be placed firmly on the part
to be percussed and placed parallel to the border of the
organ to be percussed. Bones are percussed directly with
the percussing finger (plexor) without placing pleximeter
finger, called direct percussion.
Middle phalanx of the pleximeter should be percussed
with plexor and direction of stroke should be perpendicular
rather at any other angle. Try not to strike more than two
strokes and avoid discomfort to patient by doing heavy
percussion.
After stroking the pleximeter, the plexor should be

raised immediately like ball thrown to the wall as it
prevents damping the percussion note. However, in obese
and very muscular subjects, heavy percussion is advised.
The important signs to be elicited are resonance, dullness,
pain and tenderness. Both sides should be compared
systematically.
In coarse percussion three or four fingers are tapped
together lightly on each side and comparison is made. On
the back, the scapulae should be moved out by asking
the patients to put his hands over his shoulders on
opposite sides to elicit percussion in a better way.
Do not forget to percuss the lateral aspect of chest by
asking the patient to keep both hands over his head.
Principles of Auscultation
For auscultation of the respiratory system, the diaphragm
of a stethoscope is used. It is a misnomer as with a scope
you see but with it you hear! Before one goes on to
auscultate the chest, it is important to know how to use
stethoscope and one should make oneself familiar to its
use to increase the utility of stethoscope.
General Instructions for the Use of Stethoscope

1. Ear pieces should fit snugly into the external auditory
meatus.
2. They should be parallel to the long axis of the external
auditory meatus.
3. Warm the chest piece before putting it on the chest
of the patient by rubbing it over on to your palm.
4. Chest piece should be placed directly on the skin and
not over the clothes.
5. If the chest is hairy, moisten the hair with some water.
PEARLS
Diaphragm is for high-pitched sounds and the bell is for
low-pitched sounds. The former is suitable for high
frequency (300Hz) and the later is useful for low frequency
(150-200Hz). Low frequency sound disappears when
stethoscope is placed firmly on the skin. As most of
pulmonic and cardiac sounds are low-pitched, therefore
using the bell of the stethoscope seems logic.
Auscultation is done under the following headings:

1. Type of breath sounds.
2. Intensity of breath sounds.
3. Adventitious sounds.
4. Vocal resonance.
5. Succussion splash if there is shifting dullness.
6. Coin test (if pneumothorax is suspected).
General Principles of Auscultation

1. Patient is usually sitting on a bed.
2. Bell of the stethoscope is used.
3. Patient breathes in and out deeply with the mouth
open.
4. Avoid auscultation too close to the midline due to
normal bronchial element.
5. Hairy chest wall should be moistened with water or
the chest piece should be pressed firmly.
6. Note character of inspiration/expiration.
7. Duration and loudness of the inspiration and
expiration.
8. Presence or absence of pause at the end of inspiration
and beginning of expiration.
9. Presence of added sounds.
10. May ask the patient to cough during auscultation and

note any change in the auscultatory findings.
11. Patient is shaken during auscultation to elicit
succussion splash if there is fluid in the pleural cavity
especially in hydro-pneumothorax.
12. Patient is asked to whisper or say 123 or 99 to elicit
vocal resonance.
13. Auscultate all areas anteriorly, laterally and
posteriorly.
14. Comparison of both sides is important and is required
on the examination.
15. Comment on character of breathing, i.e., normal or
abnormal sounds including crackles, wheezing
(sibilant and sonorous), fixed monophonic, random
monophonic, inspiratory or expiratory polyphonic
and aeogophony, bronchophony and pleural rub.
STEP BY STEP EXAMINATION OF

RESPIRATORY SYSTEM (FOR LONG CASES)
The Candidate
permission of examination.
light is adequate.
5. Does a general survey (panoramic view) of the patient,
while exposing.
6. Looks at the neck and inter-costal spaces for exertion
of accessory muscles of respiration.
7. Looks at the neck for engorgement of neck veins,
abnormal pulsations during respiration and any
abnormality in supraclavicular fossae and
demonstrates pulsus paradoxus if indicated.
8. Looks from the front and side for any chest deformity
(barrel shaped chest, pectus excavatum, pectus
carinatum, kyphosis, etc).
9. Looks at the lips, tongue and finger tips for cyanosis
both central and peripheral.
10. Examines the nails for clubbing i.e., demonstrates
fluctuation and notes the nail angle obliteration etc.
11. Inspects the chest for rate, depth and type of breathing.
12. Looks at the skin closely for pigmentation, scars and
any abnormal blood vessels, abnormal swellings and
gynaecomastia.
13. Locates the apex beat from the front and side of the
patient at a level and notes any abnormality in
pulsation.
14. Inspects the patient from the foot end for movements
and expansion of the chest.
15. Palpates the trachea and notes any tracheal tug.
16. Palpates for apex beat, parasternal heave and supra-
sternal/epigastric pulsations.
17. Palpates the movements of the chest, both in upper
and lower zones (i.e. above and below the nipples).
18. Palpates for vocal fremitus on both sides of the chest.
19. Percusses the chest with correct technique as
mentioned previously (see principles of percussion),
above, on and below the clavicles.
20. Percusses for cardiac dullness and upper border of
the liver.
21. Percusses in the axillary areas.
22. Auscultates (on corresponding areas).
23. Auscultates for breath sounds on normal and deep
breathing.
24. Elicits whispering pectoriloquy if bronchial breathing
is present.
25. Auscultates any added sounds on deep breathing and
coughing
26. Auscultates for vocal resonance on front and sides.
27. Makes the patient sit up in appropriate position (i.e.
squatting with hands on opposite shoulders and back
turned towards the candidate).
28. Inspects for any deformity, swelling and scars.
Inspects for any asymmetry of movements in the chest.
29. Palpates any obvious swelling or deformity.
30. Palpates the movements at the apices.
31. Palpates for the movement of the rest of the chest.
32. Measures the chest expansion with a measuring tape.
33. Palpates and compares vocal fremitus on both sides.
34. Percusses on corresponding areas.
35. Percusses for spinal tenderness and notes the quality
of resonance.
36. Auscultates for breath sounds with normal and deep

breathing.
37. Auscultates for whispering pectoriloquy; if bronchial
breathing is noted.
38. Auscultates for post-tussive crackles after asking the
patient to cough.
39. Auscultates for vocal resonance after coughing.
to dress up and helps him doing so if necessary.
examiner.
CASE WRITING TIPS (RESPIRATORY SYSTEM)

A. Upper respiratory tract (inspection)
1. Nose
2. Para nasal air sinuses
3. Oropharynx
a. Tonsils
b. Tonsillar pillars
c. Posterior pharyngeal wall.
B. Lower respiratory tract (inspection)
1. Shape of the chest
2. Symmetry
3. Position of mediastinum
a. Trachea
b. Apex beat.
4. Movements with respiration
a. Rate
b. Rhythm
c. Type
d. General expansion
e. Comparison
f. Scars
g. Pulsations
h. Prominent blood vessels
i. Fullness of neck veins and supra-clavicular
fossae.
C. Palpation:
1. Position of mediastinum
a. Trachea
b. Apex
c. Tracheal tug.
2. Movements: Compare and measure both sides
3. Vocal fremitus
4. Intercostal space tenderness.
D. Percussion:
1. Superficial cardiac dullness (sometimes not
necessary)
2. Upper border of the liver
3. All over the chest on both sides over the lung and
pleural area
4. Shifting dullness especially in hydro-pneumothorax
E. Auscultation:
1. Type of breath sounds
2. Intensity
3. Adventitious sounds
4. Vocal resonance
5. Succussion splash (hydro-pneumothorax)
6. Coin test (pneumothorax)
7. Aeogophony/bronchophony
COMMON COMMANDS
These may be useful during short cases and may be single
or combined. The candidate may be asked to do any aspect
of the examination of the chest either from front or back
or both.
For example:
Inspect and palpate the chest (whole)
Percuss and auscultate the chest (whole)
Inspect and auscultate the chest (whole)
Palpate and auscultate the chest (whole).
Therefore a variety of combination of commands may be
asked from the candidate from the following list:
1. Inspect the chest from the front
2. Palpate the chest from the front
3. Percuss the chest from the front
4. Auscultate the chest from the front
5. Inspect the chest from the back
6. Palpate the chest from the back
7. Percuss the chest from the back
8. Auscultate chest from the back.
RESPIRATORY SYSTEM
Commands for Short Cases
Following section is based on common commands given
to the candidates for examination of the respiratory system
and it is very essential to listen carefully what the examiner
says or read carefully what ever instructions are written
on the wall near the bed of the patient. One should follow
that strictly to save the time and to present the case
properly. Therefore, repeated practice is required.
The commands may include a single aspect of
examination or two at the most i.e. inspection only or
inspection and palpation or percussion and auscultation.
Sometimes the commands may be to examine the patients
chest form the front or from the back, then you have to
repeat all the steps one by one i.e., inspection, palpation,
percussion and auscultation in a systematic way. Never
forget to examine the lateral aspect of the chest.
Therefore it is of utmost importance to listen to the exa-
miner carefully and then carry out the relevant examination.
If you have ample time left, then you can have a quick
general physical examination looking only for those clues
in particular, which might help reaching the diagnosis.
But this should be done at the end of your case when
some time is left. For this, you can either ask permission
from the examiner or do at your own to impress the
examiner.
Make sure that when you give an instruction to the
patient then after doing that particular manoeuvre, ask
him to undo that e.g., if you asked the patient to hold
the breath then ask him again to breath normally, if the
patient is asked to clench the teeth then ask him again
to relax, if the patient is asked to put the tongue out then
ask him again to put it back, etc.
COMMON COMMANDS (EXAMINATION OF THE

RESPIRATORY SYSTEM)
Inspect the Chest (See also Principles of Inspection

on Page 66)
(The candidate will inspect both the anterior lateral and
posterior aspects of the chest)
The Candidate
modesty.
6. Examines and comments on the findings of upper
respiratory tract and looks for any abnormal
pulsations, scars, blood vessels and swellings over
the chest.
7. Checks the respiratory rate.
8. Goes at the end of the bed and inspects the shape
of the chest wall.
9. Notes down the symmetry of the chest wall.
10. Notes the movements of the chest.
11. Notes the type of breathing i.e., thoracoabdominal or
abdominothoracic.
12. Comments on the apical impulse by looking at a
tangent to the chest wall.
13. Looks particularly to the intercostal muscles and in-
drawing of the subcostal area during respiratory
effort.
For the inspection on the back of chest the candidates does

following:
1. Asks the patient to sit up on a stool or at the edge
of the bed with his legs hanging down and arms crossed
in front of the chest and hands placed on opposite
shoulders.
2. Goes on to the back of the patient.
3. Looks carefully at the back of the chest.
4. Looks for any deformity of the chest wall including
spine.
5. Notes any scars, swellings, or other lesions.
6. Comments on movements of the chest.
For inspection of the lateral chest wall, the candidate asks
the patient to place his hands over his head and repeats
all the steps of inspection on both the lateral side of the
chest and comments on his findings.
PEARLS
a. The candidate should be able to pick up and define
deformities like barrel chest, funnel chest, pectus
excavatum, pectus carinatum, kyphosis, gibbus
deformity, rickety rosary and Harrisons sulcus.
b. The candidate should be well aware of the types of
respirations, shapes of the chest.
Palpate the Chest (See also Principles of Palpation

on Page 67)
Palpates the chest from front and back. Also palpates the
apical impulse.
The Candidate

modesty.
6. Palpates for trachea, checks for tracheal tug if
indicated and notes the findings.
7. Palpates for any tenderness on the front of the chest
and feels for epigastric pulsations.
8. Palpates the apex beat and locates it. Notes down
it character.
9. Checks and comments on the movements of the chest
and compares it during inspiration and expiration.
10. Checks and compares movements at apices, infra-
clavicular areas and upper interscapular areas.
11. Checks for vocal fremitus and compares on both sides
noting whether increased or decreased or absent.
12. Palpates in various intercostal spaces for any
tenderness. Mention the lateral aspect of the chest:-
13. Asks the patient to sit up on a chair or at the edge
of the bed with his legs hanging down and arms
crossed in front of the chest and hands placed on
opposite shoulders.
14. Goes on to the back of the patient.
15. Does the same steps as mentioned above on the back
of the patient.
16. Also palpates lightly the spine for any tenderness.
17. Palpates with the same method on the lateral aspects
as well.
PEARLS
a. Ulnar border of hand is most sensitive therefore it is
commonly used to feel for vocal fremitus.
b. Compare three levels anteriorly, one or two laterally
and three posteriorly.
Percuss the Chest (See also Principles of Percussion

on Page 68)
To do this examination, it is advised to make the patient
sit up on a stool or edge of the bed. If the patient is lying
on the mattress, it may lead to damping effect resulting
in difficulty in eliciting this examination.
The Candidate
modesty.
6. Starts from the apices.
7. Percusses the clavicles either directly or stretches the
skin over the clavicles with index and ring fingers
of his left hand (if right handed and vice versa) on
each side in parallel to clavicle and uses them as
pleximeter including clavicle so that area above,
behind and below clavicle is percussed with the
plexor of the right hand.
8. Percusses following the principles of percussion
(already discussed) and compares both sides on the
front.
9. Percusses the upper border of the liver.

10. Asks the patient to put his hands over his head and
percusses the lateral chest walls including axillae and
compares them.
11. Repeats the same procedure on the back of the chest
but asking the patient to put his hands on the
opposite shoulders with arms crossed in front of his
chest.
Repeats the same procedure for lateral sides of the
chest after asking the patient to put his hands over
his head.
12. Percusses the spine to elicit any tenderness.
PEARLS
a. Candidate should know types of different resonances
i.e., tympanitic, resonant, hyper-resonant, impaired,
dull, stony dull, cracked pot (cavity with a patent
bronchus) and bell tympani.
b. The normal lower limits of the lung in mid-inspiration
are the sixth space in the mid-claivcular, eighth space
in mid-axillary and tenth space in mid-scapular line.
Check for Liver Dullness (Upper border)

(Explain the procedure to the patient)
The Candidate
modesty.

6. Percusses the right cardiac border first by percussing
in parallel to the border.
7. Percusses downward spacewise from the right second
intercostal space in the mid clavicular line.
8. Keeps the finger parallel to the lower edge of the lung.
9. Continues downwards until the liver dullness is
observed. (This is the upper border of the liver)
10. Localizes the upper border of the liver by counting
the inter costal spaces starting from 2nd intercostal
space (in reference with the angle of Louis)
11. Defines the liver dullness in mid-clavicular, mid-
axillary and mid-scapular lines.
PEARLS
A huge cardiomegaly can give the impression that the
upper border of the liver is quite high. Therefore,
cardiomegaly should be ruled out first.
Auscultate the Chest (See also Principles of

Auscultation on Page 69)
The Candidate
modesty.

6. Makes the patient in sitting position.
7. Asks the patient to keep on taking deep breaths in
and out regularly.
8. Uses diaphragm of the chest piece of the stethoscope.
9. Auscultates all areas of the lung on the front, back
and lateral sides of the chest.
10. Compares the auscultatory findings simultaneously.
11. Auscultates if necessary after making the patient
cough.
12. Auscultates for vocal resonance having instructed the
patient to say 123 or 99.
13. Compares vocal resonance on corresponding areas.
PEARLS
a. Normal breathing is vesicular, other types are bronchial
breathing which may be tubular, cavernous or
amphoric or it may be bronchovesicular breathing.
Candidates should be able to pick them up during
auscultation.
b. Other sounds are called adventitious sounds e.g.,
wheezing which may be fixed, monophonic,
polyphonic, sibilant, and sonorous (depending on the
size of the airway constricted). Others include crackles
(fine or coarse) and pleural rub.
c. In normal vocal resonance, sound appears to be
produced at the chest piece. If sounds are produced
near the ear, it indicates increased vocal resonance.
In bronchophony, sounds appear to be produced at
the ear piece. In whispering pectoriloquy even the low
intensity spoken sounds are clearly heard right in the

ears of the examiner. In aeogophony the sounds have
a nasal quality due to high pitch.
Check for the Tracheal Tug
The Candidate
modesty.
6. Makes the patient sit up.
7. Approaches from the front.
8. Raises the chin of the patient straight up.
9. Puts first three fingers of the right hand (vice versa
if left handed) together (index, ring, and middle)
vertically over the supra-sternal notch.
10. Asks the patient to breathe in.
11. Notes the movement of trachea during inspiration.
12. Feels for the cricoid cartilage.
13. Notes the findings.
14. Helps the patient re-dressing if necessary.
PEARLS
a. Tracheal tug is felt in case of pulmonary fibrosis. It
is also felt in cases of aortic arch aneurysms.
b. In case of aortic arch aneurysm, one feels a downward
tug for each heart beat.
Check for Tracheal Position

The Candidate
modesty.
6. Makes the patient lie down supine.
7. Puts his index finger on the right sternoclavicular
joint and ring finger on the left sternoclavicular joint.
8. Feels the trachea with middle finger and notes its
position.
9. Helps redressing the patient.
10. Thanks for his cooperation.
11. Comments on the findings.
PEARLS
In one finger method, the patient is supine and the
candidate uses his index finger sliding through the supra-
sternal notch and feels for trachea and comments on the
findings.
Percuss for Elliss Curve (See also Principles of

Percussion on Page 68)
The Candidate
modesty.
6. Makes the patient in sitting position.
7. Percusses the upper level of pleural effusion
anteriorly placing patients upper limbs by his side.
8. Asks the patient to raise his hands over his head
and percusses the upper level of effusion laterally.
9. Asks the patient to put his hands on opposite
shoulders crossing his limbs on the front of chest
and percusses the upper level of effusion posteriorly
or on the back.
PEARLS
a. In moderate pleural effusion, the upper level of effusion
is higher in the axillary area due to capillary action
of the pleural surfaces and it forms a curve with
concavity upwards called Elliss curve on a chest
X-ray.
b. If the level is same on the front side and back of the
chest with hyper-resonant area above, this indicates
hydropneumothorax.
Elicit Succussion Splash
The Candidate
modesty.

6. Makes the patient sit up on the bed.
7. Stabilizes the opposite shoulder of the patient.
8. Shakes the ipsi-lateral shoulder strongly.
9. Listens on the same side for succussion splash with
stethoscope.
PEARLS
a. Another method for eliciting succession splash is to
make the patient lie down in left decubitus posture
and shake the right side and listens for splash on the
same side with stethoscope
b. It is heard if there is a large pneumothorax with
moderate amount of fluid.
N.B.: This part of examination is rarely asked to do now-
a-days!
Examine for Diaphragmatic Palsy

The Candidate
modesty.
7. Percusses the chest posteriorly from above.

8. Asks the patient to take a deep breath and hold it.
9. Percusses again to determine the lower level of
percussion (this indicates lower border of the lung).
10. Asks the patient to exhale fully and hold the breath
in full expiration.
11. Determines the lower level of percussion (in full
expiration).
12. Examines and compare both sides.
PEARLS
a. The movements are absent in diaphragmatic paralysis
on that particular side. Normal gap should be about
2 intercostal spaces but in palsy it is absent. The
movements are reduced in pleural and pulmonary
diseases.
b. Another method is a bit simple, involves patient to be
in supine position. The palm of one hand is placed
on the lower inter costal space and the other hand is
placed over the abdominal wall on the same side below
the sub costal margin. Ask the patient to breathe in
and out normally. Normally during inspiration both
hands move upwards where as in diaphragmatic palsy
the hand placed on abdomen will move downwards
called paradoxical movement.
c. A third method involves the patient to lie down supine
with light coming from window, the examiner faces
the patients. The arms are placed under the head of
the patient. The examiner inspects the seventh to tenth
ribs in the mid axillary line and looks for movement
of rib shadows which moves either up or down and

examines and compares both sides. The diaphragm is
attached from 7th to 10th rib. If the diaphragm is
paralyzed the movement of shadows is absent.
d. Right diaphragm is slightly above the left (approxi-
mately 2.5 cm).
Check for Spinal Tenderness (See also Principles of

Percussion of Page 68)
The Candidate
modesty.
6. Makes the patient sit on a stool or a couch.
7. Palpates the cervical, upper thoracic, lower thoracic
and lumbar spinous processes separately pressing
with his right thumb.
8. Percusses lightly on these spinous process for
evidence of tenderness with four fingers joined
together. (This is called light percussion)
9. Makes a fist and with the ulnar border percusses from
upper thoracic area to lumbar region.
10. Places the palm of left hand over the spine and with
the ulnar border of the of right hand, taps strongly
the dorsum of the left hand and moves from above
down to the lumbar area. (This is called heavy
percussion).

PEARLS
Spinal tenderness may be due to some infective, traumatic
or malignant process.
Do the Coin Test
The Candidate
modesty.
6. Instructs the patient properly about the procedure.
8. Places firmly one coin flat on the anterior part of the
right or left chest.
9. Percusses the coin with an another coin (for step 8-
9 examiner needs assistance)
10. Listens on the back with the diaphragm of the
stethoscope on the same side.
PEARLS
a. The coin test is positive if high-pitched ringing sounds
are heard along with each percussion step. The test
is negative if low-pitched butting sound is heard.
b. The sites for percussion and auscultation can be
changed. But make sure it is over a hyper resonant
area. Coin and diaphragm of the stethoscope should
be as away as possible.
c. This test is performed in pneumothorax and hydro-
pneumothorax when there is free air in the pleural
cavity.
d. You can note that it is a combination of percussion
and auscultation simultaneously, therefore, you need
an assistant to place the coin on the chest wall and
percuss it with another coin for you.
CHAPTER 7
Examination of
Cardiovascular
System

1. Principles of examination of cardiovascular system
2. Examination of the cardiovascular system as a whole
(for long case)
3. Schematic out line of cardiovascular system
4. Common commands in cardiovascular system (for
short cases).
PRINCIPLES OF EXAMINATION OF
CARDIOVASCULAR SYSTEM
Before starting one should know briefly the surface
markings of the heart and certain principles of the
examination of the cardiovascular system. These principles
include inspection, palpation, percussion and auscultation.
Principles
The examination of the cardiovascular system (CVS) starts
with the basic knowledge of surface anatomy of the heart
and great vessels. For the purpose of examination, the CVS
is subdivided into two:
1. Peripheral cardiovascular system (CVS)
2. Central cardiovascular system (CVS)
A detailed cardiac history is mandatory before going
over to the examination of the system.
A methodical approach is advised with inspection of
the patient with particular stress on any deformity of the
chest, on the JVP, the radial pulse, the carotid pulse and
other pulsations in the precordium. Then palpation of the
apex beat and auscultation of all the four areas and others
where indicated. Percussion is not done very frequently
in cardiovascular system examination. Auscultation of the
lungs and bases and its percussion along with the
examination of peripheral pulses including carotid or
femoral bruits is important and should not be overlooked.
EXAMINATION OF CARDIOVASCULAR SYSTEM 95
Expose the patient properly and then give a general
panoramic view of the patient and note down any striking
abnormality.
Chest deformity is easily picked up in the form of pectus
excavatum or carinatum. Look for any visible precordial
pulsations. Inspect the apex beat at a tangent from the
left side and the JVP while the patient is lying in the bed
with the head raised at an angle of 45 from the right
side. If apex beat is not seen, state that the apex beat
is not seen. Look closely for any collateral blood vessels
over the chest wall in the front, back and lateral sides
of the chest. Look carefully at the pulmonary, aortic, left
parasternal, epigastric, suprasternal notch and carotid
areas. Inspect for pallor, cyanosis, rashes, clubbing and
splinter haemorrhages in the nails, Janeway lesions and
Oslers nodes in the hands over the palms and finger pulps
respectively. Also look for oedema which will be visible
as shiny, stretched skin of lower limbs.
Palpation of CVS starts from the pulses especially the
radial pulse and its characteristics are noted down i.e.,
rate, rhythm, volume, character, arterial wall condition,
comparison with other radial pulse and the radio femoral
delay is noted. (It is discussed under examination of the
pulses in more detail). Next important step is the
measurement of the blood pressure in both supine and
erect posture. (It is discussed in detail under the
examination of blood pressure). Then palpate for the apical
impulse inferolateral to the anterior chest wall in the
midcalvicular line on the left side of the chest and point
out exact location of the apex with the pulp or tip of your
index finger making a perpendicular. To locate its exact

position, count down from the left midclavicular area,
intercostal space wise and note down exact location of
the apex beat. You can also relate its location in reference
to anterior axillary or mid axillary line. During palpation,
look for character of the impulse and note down whether
tapping or heaving by lying patient on left lateral position.
Feel for any thuds, heaves or thrills at different areas of
the precordium. Feel also for metallic sounds in case of
artificial heart valves. Also check for poedal or sacral
oedema by pressing firmly with thumb for at least 15-30
seconds and note any pitting oedema over there.
Principles of Percussion
This part of the examination is usually not performed as
a routine but by percussing the various borders of the heart
in their line may indicate enlargement of the cardiac size.
However, it is sometimes necessary to percuss right
border of heart before percussing upper border of the liver.
Comment and describe dullness in different areas.
Left border is percussed in supine position after
localization of the apex beat. Start percussing one inter-
costal space above and about 1-2 cm lateral to the apex
beat and proceed medially till the site of impaired
percussion note is noted and mark with a skin pencil,
and proceed space wise and mark again. A line joining
these points of the heart will indicate left border.
Right border is in 3rd and 4th intercostal spaces on
the right side of the chest extending just lateral to the right
border of the sternum (not more than 1cm). First locate
the upper border of the liver (described already
under respiratory system) and then start percussion at the
mid-clavicular line, one space above the liver surface
towards the medial side. Normal liver dullness is in the

5th intercostal space in mid clavicular line. If it is extending
at 4th intercostal space then cardiac border can be
identified in the 3rd intercostal space and if upper border
of liver is in the 3rd intercostal space then one cannot
identify the right cardiac border by the method of
percussion.
If liver is pushed down i.e., in the 8th intercostal space,
one needs not to percuss the cardiac border in the 7th
space. Percussion should be done in the usual space i.e.,
4th and 3rd intercostal spaces.
Upper border of heart is in 3rd intercostal space near
the sternum and the dullness is masked by the lung
resonance.
Sternum is percussed by direct method.
Principles of Auscultation
The vicinity should be quiet and it should be timed with
the carotids. This aspect of examination makes the actual
backbone of the CVS examination. This also requires a
lot of practice to become tuned to various sounds produced
at the precordium by various pathologies of the valves
myocardium and pericardium.
(Please read the section on the use of the stethoscope
on page 69.)
Follow a set pattern for auscultation and during this
simultaneously palpate carotid for timing the sounds and
murmurs at the apex, the epigastric, the pulmonary and
the aortic areas or in the reverse order.
Auscultate in all the areas of pre-cordium (4 areas)
and listen for 1st heart sound at mitral area and tricuspid
area and second heart sound at the pulmonic and aortic
area and note down intensity in terms of normal, muffled
or loud. Note particularly any opening snap and for this

purpose, use the diaphragm of the stethoscope and tilt
the patient towards his left side if indicated. You should
practice to listen to 3rd and 4th heart sounds and comment
on their presence or absence.
Listen carefully for murmurs at mitral, aortic,
pulmonary and tricuspid area and note down its relation
to cardiac cycle whether systolic, diastolic, the site it is
best heard, and make position of the patient for better
hearing if you have to do so. You should know which
murmur is heard better with either diaphragm or bell
depending upon its pitch. Note also the relationship of
the murmurs with respiration i.e., inspiration or
expiration. Note the high or low pitched murmurs and
site of radiation in the surrounding area.
Listen carefully for any pericardial rub and instruct
the patient accordingly to hold breath when it is heard
both during systole and diastole.
Listen for the bruit at carotid area and also over the
scapulae in case of coarctation of aorta.
PEARLS
a. Bell is used for low-pitched sounds of mid diastolic
murmur of mitral stenosis or the third heat sound of
cardiac failure. Diaphragm is ideal for second heart
sound, for ejection and mid systolic clicks and soft high
pitched early diastolic murmur of aortic regurgitation.
b. For auscultation, start from apex (i) then left lower
sternal edge (ii) then left upper sternal edge (iii) and
then right upper sternal edge (iv). These locations
correspond with the mitral, tricuspid, pulmonary and
aortic areas respectively.
c. 4th heart sound occurs late in the diastole. When 3rd

heart sound is also present they give a gallop to the
cardiac rhythm. Both are best heard with bell at cardiac
apex.
d. Listen over the base of the lungs for crackles and for
the evidence of cardiac failure.
e. If tricuspid regurgitation is suspected palpate the liver
for pulsatility.
f. Also elicit hepato-jugular reflux.
g. Ask for valsalva manoeuvre for changing character or
intensity of the murmurs.
PEARLS
Grading of the Murmurs
Grade I: Just audible with the stethoscope in quiet
room
Grade II: Quite readily audible with stethoscope
Grade III: Easily heard with stethoscope
Grade IV: Loud obvious murmur
Grade V: Very loud, not only on the precordium but
elsewhere in the body.
Other system of grading is as follows:
Grade I: Heard only with special manoeuvres
Grade II: Faintly heard
Grade III: Well-heard but without thrill
Grade IV: Well-heard but thrill is present
Grade V: Loud
Grade VI: Very loud, heard with a stethoscope where
chest piece is held a few millimetres away
from the chest wall.
Dynamic Auscultation
In this certain manoeuvres are made to intensify the
murmur. They are useful to hear a murmur which is of
low intensity. These manoeuvres include sustained hand
grip, transient arterial occlusion which usually increase
the murmurs of mitral and aortic regurgitation, squatting
which increases intensity of most of the murmurs, valsalva
manoeuvre and standing which decrease intensity of most
murmurs except mitral valve prolapse and hypertrophic
obstructive cardiomyopathy (HOCM). Nitrates increase the
intensity of murmur of aortic stenosis.
First heart sound is best heard at apex. Second heart
sound is best heard at the base.
For murmurs, comment as follows:
1. Systolic or diastolic
2. Grading of the murmurs (I-VI see above)
3. Pitch of the murmur
4. Shape of the murmur
5. Area best heard
6. Area of selective conduction
7. Dynamic auscultation
Do not limit auscultation at 4 areas of valves
respectively but proceed towards the left axilla from mitral
area, to the epigastric region from the tricuspid area, to
the left 1st intercostal space from the pulmonary area, to
the right 3rd and 4th intercostal spaces from the aortic
area and also to the carotid arteries for radiation.
These accessory areas can act as gold mine of
information when main area may appear silent. Some
cardiac murmurs may be heard up to the occiput or to
the coccyx.
Murmurs originating on the right side of heart are better
heard during inspiration and murmurs on left side of the
heart are better heard during expiration.
Ask the patient to breathe normally as if patient

breathes deeply, the distance between chest wall and heart
increases, therefore intensity of the murmur may decrease
giving wrong impression.
Valsalva manoeuvre is performed by asking the patient
to blow hard on the back of his or her hand or forearm
without releasing air. It usually changes the murmurs of
HOCM and mitral valve prolapse.
STEP BY STEP EXAMINATION OF

CARDIOVASCULAR SYSTEM (FOR LONG CASE)
The Candidate
light is adequate.
by asking questions such as name, date of birth,
address, recognition of people around etc.
5. Positions him at 45 in the bed.
6. Starts with the examination of the hands and looks
at nails.
7. Looks for capillary pulsations [presses the tip of nail]
8. Looks for clubbing at tangent and tests for fluctuation
at the nail bed.
9. Palpates the finger pulps for any tender nodules.
10. For checking the radial pulse, makes proper position
[semi-prone forearm with and wrist slightly flexed
and counts for at least 30 seconds. Notes the effect
of deep inspiration, and lifts the arm with support
for checking collapsing pulse.
11. Compares the two radial pulses simultaneously.
12. Checks for radio-femoral delay
13. Examines the face for any associated clues i.e.,
Cushingoid, polycythaemic and mitral facies etc.,
depresses lower eyelids, looks inside oral cavity with
torch and tongue depressor, and asks for protrusion
of the tongue.
14. Inspects the JVP at 450 and asks the patient to take
deep breaths. Inspects carotids for any abnormal
pulsations
15. Palpates the carotids one at each time.
16. Elicits hepato-jugular reflux.
17. Inspects the chest for any asymmetry. [from feet]
18. Inspects the apex beat. [with his eyes at a tangent
to the chest level]
19. Inspects abnormal abdominal pulsations.
20. Palpates the chest at apex, left parasternal area and
base of the heart.
21. Auscultates while palpating the carotid artery (at the
start).
22. Auscultates mitral area with diaphragm and bell in
supine position.
23. Turns the patient to the left and palpates for the apex
beat and clearly instructs him on how to hold his
breath in complete expiration.
24. Auscultates mitral area with bell of the stethoscope
in this position with breath held in expiration and
asks patient to resume breathing immediately
afterwards.
25. Auscultates tricuspid area with the diaphragm and
bell of the stethoscope in supine position and notes
the effects of respiration.
26. Auscultates pulmonary and both aortic areas with
the diaphragm in supine position and notes the
effects of respiration.
27. Sits the patient up and clearly instructs him on how
to hold his breath after complete expiration while
leaning forward.
28. Auscultates the base of the heart with diaphragm in
this position and asks the patient to resume breathing
immediately afterwards.
29. Auscultates over carotids and left sternal border.
30. Auscultates over other areas if indicated (for any
radiation).
31. Auscultates the lung bases.
32. Checks for sacral oedema.

33. Makes the patient stand up and notes effect of exercise
if indicated (dyspnoea, chest pain and disappearance
of VPBs)
34. Notes down any postural drop in blood pressure.
35. Makes the patient lie down and palpates the liver.
36. Palpates the spleen [if indicated]
37. Examines the legs for ankle oedema, calf tenderness,
and leg pulses.
38. Performs fundoscopy (if required)
to dress-up and helps him if necessary.
40. Notes down all the findings and comments while
CASE WRITING TIPS

Peripheral CVS
1. Radial pulse:
Rate
Rhythm
Volume
Character
Condition of arterial wall
Comparison of volume
Radio-femoral delay
2. Other peripheral pulses
3. Blood pressure:
Lying
Standing.
4. Signs of CCF:
Raised JVP
Tender hepatomegaly
Bibasal crackles
Poedal oedema
5. Miscellaneous:
Clubbing
Cyanosis
Pallor.
Central CVS
1. Inspection:
Shape of precordium
Apex beat
Pulsation in other areas
a. Pulmonary
b. Parasternal
c. Aortic
d. Neck
e. Epigastric
f. JVP
2. Palpation:
i. Apex beat localization
ii. Pulsation in following areas
Pulmonary
Parasternal
Aortic
iii. Thrills:
Mitral
Aortic
Carotid artery
Pulmonary
Parasternal
iv. Palpates liver for hepatojugular reflux,
v. Feels for pulsatile liver
vi. Palpates for oedema.
3. Percussion:
i. Cardiac borders:
Left
Right
Upper (base).
ii. Superficial cardiac dullness

iii. Pulmonary area
iv. Sternum
Upper part
Lower part.
v. Aortic area
4. Auscultation:
i. Heart sounds:
Mitral area M1
Pulmonary area P2
Aortic area A2
Tricuspid area M1
Opening snap
ii. Murmurs:
Mitral area
Aortic area
Bruit over carotids
Pulmonary area
Tricuspid area
Parasternal area
iii. Pericardial rub
iv. Listening to the base of lungs.
COMMON COMMANDS
1. Look for the JVP
2. Inspect the precordium
3. Palpate the precordium
4. Auscultate the precordium
5. Auscultate the apical area (Mitral area)
6. Auscultate the base of the heart (Aortic and pulmonary
areas)
7. Auscultate aortic area and palpate the apex beat
8. Look for signs of cardiac failure.
Look at the Jugular Venous Pressure (JVP) or

Examine the JVP
The Candidate
modesty.
6. Makes the patient lie in the bed at an angle of 45
between his trunk and hip.
7. Supports the neck on a pillow to relax the muscles
of the neck.
8. Turns the face slightly to the opposite side to avoid
shadow of the lower jaw.
9. Looks at internal jugular vein tangentially.
10. Maintains patients trunk and neck in one line.(do
not tilt the neck forward)
11. Puts one scale at the sternal angle perpendicular to
the bed.
12. Puts another scale from the highest point of JVP

parallel to the bed to meet the vertical scale.
13. Measures the height of the vertical scale from the
sternum. Thus indicating the JVP in centimetres of
water.
14. Checks the disappearance of pulse wave form by
pressing lightly at the base of the neck.
15. Performs hepatojugular reflux.
PEARLS
a. Candidate should know the causes of raised JVP.
b. The junction of the distended and the collapsed vein
is the upper level of the JVP.
c. The wave occurring just before carotid pulse is a wave
and that occurs with down stroke of carotid pulse is
v wave.
d. The jugular veins are in direct communication with
the right atrium, they act as manometer to reflect the
pressure changes of the right atrium.
e. Kussmauls sign is the rise of JVP during inspiration
(normally it should fall) and usually occurs in
constrictive pericarditis or cardiac temponade.
i. a is produced by atrial systole. (Ascent)
ii. c is produced by tricuspid valve ring closure
(Descent)
iii. x is produced by lowering of tricuspid valve
(Descent)
iv. v is produced by rising atrial pressure due to
tricuspid valve closure. (Ascent)
v. y is produced by opening of tricuspid valve

resulting in lowering of pressure (Descent)
Inspect the Precordium (See also Principles of

Inspection on Pages 66 and 95)
The Candidate
modesty.
6. Makes the patient lie supine in the bed (Makes him
sit if orthopnoeic).
7. Looks for any bulge over the precordium tangentially
from the side and from the foot end of the bed.
8. Looks for any scar of previous valvotomy or
sternotomy or vessels by closely observing it.
9. Localizes the apex beat.
10. Looks for pericardial pulsations in the suprasternal,
sternal, aortic, parasternal, inter costal and epigastric
areas.
11. Looks for any chest deformities i.e., kyphosis, scoliosis,
pectus excavatum, pectus carinatum, barrel shaped
chest etc.
12. Comments about JVP if there is some spare time.
PEARLS
All you can do it without touching the patient, therefore
a close look is required, so that not much is over looked.
Palpate the Precordium (See also Principles of

Palpation on Pages 67 and 95)
The Candidate
modesty.
6. Looks for the apex beat.
7. Warms his hands, places the right hand on the left
precordium.
8. Locates the apex beat by using ulnar part of the palm
of the right hand preferably finger placed in line with
the intercostal space (In females lifts the breast)
9. Localizes the exact position (maximum impact) of the
apex beat with the tip of index finger placed vertically.
(In reference to mid clavicular line and intercostal
space).
10. Assesses the character of apex beat by asking the
patient to turn to left slightly.
11. Times with the carotid artery for any paradoxical
impulse of apex beat.
12. Uses 3 fingers (for 2nd, 3rd and 4th in each ICS
respectively to detect mild heave near the borders of
the sternum.
13. Uses ulnar border of his right hand placing parallel
to the border of the sternum for evident heave.
14. Feels for any palpable heart sounds and thrills.

15. Feels for any palpable pulsations in the epigastrium
or supra sternal notch
16. Palpates the pulse if time permits.
19. Comments on site, character of apex beat, palpable
sounds or thrills or any parasternal heave or
epigastric or suprasternal pulsations.
PEARLS
a. First inspect the apex and then palpate the point of
maximum impact.
b. If it is difficult then look for it in sitting position
making the patient to hold breath in expiration or
inspiration.
c. In left lateral position, apex beat shifts about 2-3 cm
laterally and comes closer to the chest wall. If breath
is held in expiration the apex beat is felt well as this
manoeuvre reduces the volume of lung over laying
the heart.
d. For palpating thrills, the palm is used as it is more
sensitive and for assessing movements, fingers are
better option.
e. Normal apex beat lasts for a very short time (< 1/
3 of systole) in an area of 1 cm in diameter. Hyper-
dynamic apex beat lasts < 2/3 of systole, in area >
3 cm diameter).
f. Heaving apex beat lasts more than 2/3 of systole and
in an area < 2.5 cm diameter.
g. As regards precordial impulse, it should not be
confused with apical impulse.
h. In right ventricular heave, parasternal area shows an
outwards and upwards thrust. In left ventricular
heave, the thrust is outwards and laterally.
i. In case of both left and right ventricular impulses,

both apex and parasternal areas show a thrust
outwards.
j. A double apex beat is usually due to left ventricular
aneurysm.
k. Thrills can occur both in systole or diastole.
Percuss the Heart (See also Principles of Percussion

on Pages 68 and 96)
The Candidate
modesty.
6. Asks the patient to hold his hands over his head.
7. Percusses first the upper border of the liver.
8. Holds pleximeter parallel to border of the heart to
be percussed.
9. Percusses from resonant to dull area.
10. Percusses and defines the right border, the left border
and the base of the heart (great vessels i.e., aortic and
pulmonary areas)
13. Comments on his findings while presenting to the
examiner.
PEARLS
In a thin person, directly percussing the intercostal spaces
help out lining the borders of the heart easily.
Auscultate the Precordium (See also Principles of

Auscultation on Pages 69 and 97)
The Candidate
modesty.
6. Localizes the apex beat by inspection and palpation.
7. Places bell of the stethoscope at the apex.
8. Puts his left thumb over the right carotid for timing
of the sounds (makes sure to do this when ever
auscultating any area of the heart for timing).
9. Turns the patient to the left position a little and listens
to the apical area.
10. Asks the patient to hold his breath in expiration to
clearly listen for the opening snap or a murmur of
mitral stenosis.
11. Listens up to the axilla if there is any radiation of
the murmur i.e., mitral regurgitation.
12. Listens at tricuspid area by inching method.
13. Performs dynamic auscultation if necessary.
14. Listens at aortic area by asking the patient to hold
his breath in full expiration while leaning forwards.
15. Auscultates the carotids for radiation of the murmur.
16. Listens at the pulmonic areas and asking the patient
to hold his breath in inspiration or expiration to assess
splitting of the second heart sound.
17. Listens at both parasternal areas for any added

sounds.
18. If in doubt, also listens at the scapulae for a machinery
murmur (coarctation of aorta)
examiner.
PEARLS
a. All the sounds and murmurs should be timed by
simultaneously palpating the right carotid.
b. Always comment on intensity of the heart sounds, type
of murmur, timing with the cardiac cycle and its
intensity (grading I-VI)
c. One should be able to perform dynamic auscultation,
if required.
d. One should be well aware of the use of stethoscope
(see general section page 69).
e. One should be well aware of the surface anatomy of
the heart and the location of different valves.
f. One should not limit auscultation to only four cardiac
valvular areas but should proceed to axilla, epigastric,
intercostal spaces and even on the back at interscapular
region.
g. The candidate should know what to listen at each area
as regards sounds, murmurs and other sounds at each
area.
h. Do not forget to listen to a pericardial rub while
listening over the whole precordium and asking the
patient to hold his breath in expiration to make it clear.
i. The candidate should know where to use the bell and
where to use the diaphragm of the stethoscope.
Auscultate the Heart for Gallop (See Principles of

Auscultation on Page 97)
The Candidate
modesty.
6. While the patient is lying in supine position, localizes
the apex beat.
7. Places the bell of the stethoscope at the apex and
tricuspid area.
8. Makes the patient tilt to left lateral position with breath
held in expiration.
9. Listens to 3rd and 4th heart sound.
10. Times the sounds with his thumb on the right carotids.
examiner.
PEARLS
a. S3, S4 are low pitched sounds, therefore heard with the
bell.
b. Auscultate mitral area for left sided gallop.
c. Auscultate tricuspid area for right sided gallop.
d. Gallop sounds are better heard in supine left lateral
position, with raising legs or compressing the abdomen,
during expiration and after exercise (Almost all three
manoeuvres increase the venous return to the heart
thus making these sounds a bit more prominent.
e. S1, S2, S3 sounds like running of a horse and this is

called gallop rhythm. It is also called S3 gallop or
proto-diastolic gallop.
f. S1, S2, S4 is called S4-gallop or presystolic gallop.
g. S1, S2, S3, S4 is called quadruple rhythm.
h. If S1, S2, are fused and S3 and S4 are separately heard,
it is called summation gallop.
i. S3 occurs in normal and hyperdynamic heart states and
is called physiological. It occurs due to rapid filling
of the ventricles during early phase of diastole. In the
presence of cardiac failure, it is called pathological.
j. S4 occurs late in diastole following AV valve opening
and contraction of atria. S4 may be physiological in the
elderly (>50 years) but most of the time it is pathological
when the left ventricular compliance is reduced.
k. Clicks are audible only, if the valve cusps are pliant
and noncalcified and are more prominent in
congenitally bicuspid valves (clicks produced by mitral
valve prolapse).
l. Snaps are produced by forcible opening of the
thickened valve leaflets (e.g., opening snap of mitral
stenosis).
m. The candidate should be able to comment correctly on
ejection systolic, pansystolic, late-systolic, early
diastolic, middiastolic and presystolic murmurs with
accentuation and continuous murmurs.
n. The candidate should also be able to comment correctly
on the findings of mitral stenosis, mitral regurgitation,
mitral valve prolapse, aortic stenosis, aortic
regurgitation and pulmonary stenosis, pulmonary
regurgitation, ventricular septal defect (VSD), atrial
septal defect (ASD), co-arctation of aorta and patent
ductus arteriosus.
o. The candidate should be able to pick up auscultatory

findings of the pathology of two valves simultaneously
and this needs a lot of practice of auscultation.
p. The candidate should know how to elicit pulsatile liver
and hepatojugular reflux in tricuspid regurgitation.
q. Always listen to the base of the lungs and feel for
peripheral oedema at the end of cardiac examination.
Look for Aortic Regurgitation

The Candidate
6. Locates the apex beat.
7. Listens to it carefully.
8. Listens at the aortic area.
9. Times the murmur of aortic regurgitation or aortic
stenosis by placing left thumb over the right carotid.
10. Makes the patient sit and lean forward.
11. Instructs him to inhale, then exhale fully and hold
his breath in full expiration.
12. Listens for early diastolic murmur of aortic
regurgitation at the left lower parasternal area with
diaphragm of the stethoscope.
13. Looks for other signs of aortic regurgitation as follows.
14. Checks for the collapsing pulse (see examination of
the pulse on page 49).
15. Looks at the carotids for Corrigans sign.
16. Looks at the head for nodding called the Demussets
sign.
17. Looks at the uvula for pulsation called the Mullers

sign.
18. Looks for the alternate capillary pulsations at the inside
of the lips and capillary bed of the nails by pressing
lightly with a glass slide called the Quinkes sign.
19. Listens at femoral arteries for pistol shot sounds.
20. Presses the femoral artery with the distal edge of the
diaphragm of the stethoscope lightly to listen a
diastolic murmur and presses the proximal edge of
the diaphragm of the stethoscope to listen a systolic
murmur called Durozies murmur.
21. Measures BP in lower limbs (If the difference is more
than 40 mm Hg in lower limbs and upper limb then
it is called Hills sign).
22. Performs fundoscopy to see pulsations of the retinal
vessels in aortic regurgitation.
examiner.
Palpate for the Apex Beat (See also the

Principles of Palpation on Pages 67 and 95)
The Candidate
6. Inspects the pre-cordium for apical impulse and a
gets a rough idea of its location in supine position.
7. Places the palm of the right hand at the precordium
over the left nipple.
8. In case of females, elevates the left breast and places

his right hand.
9. Feels for the impact of the apical impulse.
10. Tilts the patient slightly on the left side if feels
difficulty in locating the apex beat.
11. Notes down its location in relation to mid-sternal,
mid-clavicular or mid-axillary line by the pulp of his
index finger placed perpendicularly over the impulse
of the apex beat.
12. Counts for the intercostal space where this is located.
13. Notes down its character i.e. tapping, heaving, forcible,
double impact etc.
examiner.
PEARLS
One should master the methods for palpation, localization
and character of the apex beat.
Look for the Signs of Cardiac Failure

The Candidate
modesty.
6. Makes the patient lie down at an angle of 45 with
the lower limbs.
7. Keeps the head, neck and upper trunk in line.
8. Asks the patient to slightly turn his head towards

the left side.
9. Looks at the JVP.
10. Presses lightly over the lower part of the neck to see
the filling or any wave form.
11. Measures the level of JVP with standard method if
raised.
12. Percusses the upper border of the liver.
13. Palpates the lower border of the liver.
14. Comments on the size, surface, edge, any tenderness
or pulsations of the liver.
15. Does a hepato-jugular reflux if indicated.
16. Checks for poedal oedema (pitting).
17. Listens to the base of both lungs for crackles.
18. Checks for sacral oedema while the patient is sitting
up.
examiner.
Auscultate the Base of the Heart (See also Principles

of Auscultation on Page 97)
The Candidate
modesty.
6. Localizes the apex beat.
7. Listens at aortic area for any systolic murmurs and

times with carotid artery pulsation by placing his left
thumb over it.
8. Listens for radiation of the murmur to the carotids
by slowly moving upwards at the root of the neck
in front and then over the carotids.
9. Listens at the pulmonary area for second heart sound
or murmurs.
10. Asks the patient to take a deep breath and holds the
breath and listens for any splitting of the 2nd heart
sound.
11. Does the same manoeuvre during expiration.
12. Makes the patient sit up and asks him to lean
forwards.
13. Asks him to breathe in fully then breathe out fully
and then hold the breath in full expiration.
14. Listens for early diastolic murmur of aortic
regurgitation at the left lower para-sternal area.
15. Asks the patient to breath normally.
examiner.
PEARLS
By doing repeated practice, one should master the art of
auscultation and come up with the correct findings and
this is only possible by listening the hearts of as many
patients as possible.
CHAPTER 8
Examination of
Gastrointestinal
System (Abdomen)

1. Principles of examination of gastrointestinal system.
2. Examination of the gastrointestinal system as a whole
(for long cases).
3. Schematic out line of gastrointestinal system.
4. Common commands in gastrointestinal system (for
short cases).
GASTROINTESTINAL SYSTEM
Before going on to that it is important to know that when
you are asked to examine abdomen, then it should not
be taken purely as gastrointestinal tract but other organs
are also examined e.g., spleen, kidneys, adrenal and any
lymph nodes.
Abdomen is divided into nine (9) imaginary areas or
quadrants by two vertical lines and two horizontal lines.
The vertical lines are either from mid clavicular points
perpendicularly downwards or from mid inguinal points
vertically upwards. The first horizontal line touches the
subcostal margin i.e., tips of tenth costal cartilages. The
second horizontal line joins the highest points of the iliac
crests on both sides.
Thus the nine quadrants hence formed are called left
iliac fossa (LIF), left lumbar quadrant, left hypochondrium
(LHC), epigastrium, umbilical area, hypogastrium, right
iliac fossa (RIF), right lumbar quadrant and right
hypochondrium (RHC).
If the candidate is asked to examine alimentary system
then he should start from mouth and end the examination
at the anal area but of course including the abdominal
examination. This includes the examination of hands
followed by mouth, then conjunctivae and sclerae and
ultimately rest of the neck for any lymphadenopathy.
EXAM. OF GASTROINTESTINAL SYSTEM (ABDOMEN) 125
In hands, nutritional status (wasting, guttering), can

be estimated and nails may give quite a bit of information.
Palms can show Dupuytrens contracture, palmar
erythema or spider nevae. Other features to look for include
clubbing, pallor, koilonychia and leukonychia etc.
Mouth examination includes inspection and palpation
including the lips, angle of mouth, number and state of
teeth, state of gums, tongue (see on page 61) and inner
side of buccal mucosa, soft and hard palate and any other
abnormalities.
The four principles of examination of gastrointestinal system
apply as follows:
1. Inspection of abdomen.
2. Palpation of abdomen.
3. Percussion of abdomen.
4. Auscultation of abdomen.
PRINCIPLES OF INSPECTION IN ABDOMINAL

EXAMINATION
The patient lies flat with arms by his sides. The patient
should be exposed properly i.e., in males up to the nipples
and then to the pubic symphysis while taking in to care
the modesty. The candidate looks carefully at the abdomen
from the sides and then from the foot end of the bed.
Candidate makes a note of the shape of the abdomen i.e.,
looks for generalized fullness or distension (5-Fs i.e., fluid,
fat, faces, flatus or foetus), and localized distension. He
should also note the position, shape and any other
abnormality of the umbilicus. He should inspect the
movements of the abdominal wall and note its normality
or abnormality. He should also look for visible pulsations
in the epigastric and at umbilical region and also look
for visible peristalses of the stomach or small bowl. He
should closely look at colour of the skin of abdomen, any

striae, distended or tortuous veins and scars. The candidate
should inspect groins, testicles and penis in the male and
look at pubic hair as well (it is advised to take permission
from the examiner for this part of inspection of the
alimentary system). If you want to distinguish between
the intra-abdominal and abdominal wall swellings, ask
the patient to raise the head without supporting it, the
intra abdominal swelling will disappear, whereas
swellings in the abdominal wall become more prominent.
Ask the patient to draw abdomen in and then below
out as much as possible. These movements will
demonstrate limitation of movements of the abdominal
muscles and may localize an area of pathology.
An imaginary line joining the anterior iliac spine and
umbilicus is called spinoumbilical line. Shift of umbilicus
is indicated by the inequality of these lines on both sides.
In the males the respiration is abdomino-thoracic
where as in the females it is thoracoabdominal.
Look for recent wounds, dressings, fistulae, sinuses,
stomas and old scars.
Ask the patient to cough and observe the abdominal
wall for hernias i.e., inguinal or incisional and divarication
of the recti.
Look for any normal or abnormal bulge of the
abdominal wall and it is more obvious if seen at a tangent
i.e., at the level of the abdominal wall.
Lastly, ask the patient to point out any tender part in
the abdomen.
PRINCIPLES OF PALPATION OF ABDOMEN

The most of abdominal viscera are not palpable in their
normal state. Patient should be in supine position and
abdomen should be relaxed. Both knees are flexed and

both hips are flexed and feet are relaxed as well (Some
examiners do not ask for it). The hands should be warmed
by rubbing together if not already warm enough before
you put your hands on his abdomen. The patient is asked
to point any tender areas in the abdomen before you place
your hand on his abdomen so that the palpation should
be started away from that area. Indulge the patient in
conversation to avert his/her attention for complete
relaxation. Try to maintain palpating hand, wrist and
elbow at the same level. Use the finger tips and palmer
aspect (radial side) of the hands and try to use single hand
technique but some prefer to use both hands, then apply
pressure with the upper hand and try to feel with the
lower hand.
Palpation can be superficial, deep, bimanual, ballotte-
ment and by dipping method. In light palpation, you should
use pressure not moving deeper more than to inches.
The hand is moved with fingers together all over the abdomen
starting from left iliac, left lumbar, left hypo-chondrial then
epigastric, umbilical, hypo-gastric and then to right iliac
fossa, right lumbar region and ends at right hypo-chondrium.
It assumes a shape of an S placed horizontally as .
S
One should feel for the tone of the abdominal muscles

and tenderness by looking continuously at patients facial
expression. You should look for any masses and their
mobility, local temperature, effect on cough impulse, their
reducibility and note any abnormality to look in more details
during deeper palpation.
The wrist and elbows should not move but there
should be movement at metacarpophalangeal joints.
Avoid sudden poking with finger tips. Ask the patient
to breathe in and then push your hand gently to feel the
edge of any moving organ. In an obese patient or a very
muscular patient put left hand over the top of right hand
as mentioned before and then palpate accordingly.
It is important to note that the abdomen should be
relaxed completely for a successful palpation.
A possible order for routine palpation is to start
palpation of liver at right hypochondrium, then move over
to epigastric area, then left hypochondrium for spleen, then
move down towards umbilicus then hypogastrium and
then into each iliac fossae. The lumbar region are left until
last as they are examined bimanually by putting left hand
behind the area and right hand in front and both hands
pressing the structures in between i.e., right and left kidney
and ascending and descending colon in those areas
respectively.
It is emphasized that prior to all this procedure, one
should be well aware of these underlying organs and their
anatomy.
During ballottement, the hands of the examiner are
being placed for bimanual palpation, steady pressure is
applied with the right hand whereas a sudden push is
applied by the left hand with finger tips and if the mass
touches anterior hand, it is said that ballottement is
present. It is usually performed to palpate the kidneys and
the masses related to them.
In dipping method, the finger tips of one or both hands
are brought together in the same line and are dipped into
abdomen with sudden jerk so as to displace the fluid
(as in massive ascites) and to feel the underlying organ.
By this method details are not known. You should
say that the mass or organ is not felt with even dipping
method.
The palpation of individual organs is described in
detail under the heading of Commands on page 136.
Bimanual palpation is also important in abdominal
aortic aneurysm or any intra-abdominal pulsating mass.
PRINCIPLES OF PERCUSSION OF ABDOMEN

It provides a gentle means of localizing abdominal
tenderness and differentiates between solid and gaseous
filled structures and therefore the borders of solid organs
can be defined.
To start with, percussion is started from RIF to RHC
then to LHC to the LIF then localization of the lower and
upper border of liver. Afterwards, percuss for spleen,
bladder and uterus and in the end look for any dullness
in the lumbar areas or flanks. If later is detected then go
for shifting dullness. Start with gentle percussion then
heavy percussion but keep on looking at patents facial
expressions for any pain. Always percuss from resonant
to dull area.
Movement should be at wrist rather than at elbow of
the hand with plexor and lift up soon after striking the
pleximeter to avoid damping effect.
Percussion of individual organs and ascites is
described in individual commands section.
PRINCIPLES OF AUSCULTATION OF ABDOMEN

This is to detect intestinal peristaltic sounds, bruits over
different viscera e.g., liver, spleen, renal artery, aorta and
to listen for other sounds e.g., hepatic or splenic rub,
succussion splash etc.
It is important to note that the stethoscope should be
warmed by rubbing over your own palm and placed gently
over the abdomen. You should wait for few seconds to
minutes to hear peristaltic sounds even in normal
individuals.
Make sure that the atmosphere is quiet. Bruits may be
heard in the epigastrium down to the umbilicus and up
to inguinal regions. In portal hypertension venous hums
can be heard which are usually increased on inspiration

and during valsalva manoeuvres.
Renal artery bruit may be heard over the renal angle
after turning the patient in semi-prone or lateral decubitus
position.
For bowel sounds, stethoscope should be placed over
the right side of umbilicus and one should wait for a while.
While listening to succussion splash, place the
stethoscope holding in your in right hand over the
epigastrium while the patient is supine, then roll the
patient from side to side to listen a splashing sound of
water. Other way is to ask the patient to keep the chest
piece of stethoscope over his epigastrium and the examiner
jottles the patient with both hands to elicit splash.
For bruits, the stethoscope is placed lightly on
abdominal wall above and to the left of umbilicus. It
indicates turbulent flow in underlying vessels due to
stenosis or aneurysm.
Friction rubs over liver abscesses and splenic infarcts
should be distinguished form a pleural rub of pulmonary
disease.
STEP BY STEP FOR EXAMINATION OF

ALIMENTARY SYSTEM (FOR LONG CASE)
The Candidate
light is adequate.
recognition of people around, etc.
5. Does a general survey (panoramic view) of the patient,

while exposing.
6. Looks at the hands and arms for (clubbing,
koilonychia, leukonychia, shiny nails, palmar
erythema, flapping tremors, Dupuytrens contractures.
pulse rate, blood pressure (may ask for BP apparatus).
Looks for spider naevi, scratch marks on skin,
ecchymotic spots, tattooing).
7. Looks at the axillae (hair line, lymph nodes,
acanthosis nigricans).
8. Looks at the neck (lymph nodes, thyroid, JVP, parotid
enlargement).
9. Looks at eyes for jaundice, pallor, Kayser-Fleischers
ring, xanthelasmae, iritis, eyes signs of thyrotoxicosis).
10. Looks at the nipples and breasts in the males
(gynaecomastia).
11. Looks in the mouth and examines oral cavity (angular
stomatitis, Peutz-Jaghers pigmentation, telangiecta-
sias, aphthous ulcers, buccal pigmentation, candi-
diasis, geographical tongue, atrophic glossitis, leuko-
plakia of the tongue and smells foetor hepaticus).
12. Looks at the chest wall (spider naevi).
13. Examines extremities for (oedema, pyoderma
gangrenosum, erythema nodosum, thrombophlebitis
migrans).
14. Examines the abdomen and inspects from the side,
at level and from the foot end of the bed.
15. Inspects the hernial orifices and asks the patient to
cough.
16. Notes shape and contour of the abdomen (normal,
scaphoid, distended, asymmetrical bulge, visible
peristalsis, surgical scars, striae, visible veins, Cullens
sign, Grey-Turners sign).
17. Determines the direction of blood flow if veins are
visible (Harveys sign).
18. Palpates the abdomen.

19. Makes sure the hands are warm in cold weather.
20. Asks the patient to relax, may ask the patient to bend
the knees and flex the hip.
21. Asks if there is any tender area.
22. Performs light palpation in S shaped manner
(visceromegaly, masses or tender areas)
23. Performs deep palpation.
24. Palpates the liver and measures the span (determines
the upper border of the liver).
25. Palpates the spleen, first in supine position, if not
palpable than in right lateral position and compresses
left lower chest wall anteriorly with left hand, while
palpating in deep inspiration.
26. Palpates right and left kidneys bimanually and elicits
ballottement.
27. Palpates the gallbladder, urinary bladder, and feels
for the divarication of recti, paraaortic lymph nodes
and other abnormal masses.
28. Palpates the hernial orifices.
29. Examines the testes for testicular atrophy (always asks
for the patients and, examiners permission).
30. Percusses for liver and splenic dullness, measures
enlarged liver, spleen and total liver span (in
centimetres).
31. Percusses the urinary bladder.
32. Percusses for the shifting dullness.
33. Percusses for fluid thrill.
34. Auscultates bowel sounds (30 seconds minimal and
for 3 minutes if absent). Notes its character.
35. Listens for hepatic bruit and hepatic rub, renal bruit,
aortic bruit and splenic rub and venous hums of portal
hypertension.
36. Demonstrates succussion splash if appropriate.
37. Asks the permission for rectal examination of the

patient from the examiner.
38. Asks the patient to stand up; checks BP again for
orthostatic changes (if appropriate), looks for
abdominal veins, (if they fill now while patient is
standing) looks at the hernial orifices (asks him to
cough).
to dress up and helps him doing so if necessary.
CASE WRITING TIPS

Inspection
General: Encephalopathy, weight loss, obesity, cachexia,
dehydration, hypo or hyper pigmentation.
Hands: Palmar erythema, telangiectasia, Dupuytrens
contracture, skin laxity, muscle wasting, liver flap,
Nails: Clubbing, koilonychia, leukonychia, pallor.
Head and Neck: Conjunctival pallor, jaundice, xanthelasmae,
halitosis, tongue, gingivitis, dentition, cervical lymph
nodes, salivary glands for enlargement and tenderness.
Abdomen: Supine, single pillow under the head and the
abdomen should be relaxed with proper exposure but with
the genitalia covered.
Inspection: Skin laxity, scars, fistulae, sinus, stomas, scratch
marks, pigmentation, striae, hair distribution, veins,
divarication of the recti, abnormal pulsations, abnormal
bulges, visible peristalsis.
Umbilicus: Position, hygiene, nodules or discharge.
Shape of abdomen: Distension, scaphoid, respiratory
movements.
Enlarged organs: Liver, spleen, kidneys, gallbladder,

uterus, urinary bladder, any other masses.
Discomfort on blowing out/drawing in abdominal wall
and response on coughing.
Percussion: Percuss in four quadrants, note rebound
tenderness, hyper resonance, position of the liver, spleen,
bladder and uterus, masses, ascites, shifting dullness.
Palpation: Watch patients face throughout.
Superficial palpation: Tone, tenderness, masses,
Deep palpation: Liver, spleen, kidney and any other
masses.
Dipping method in moderate to massive ascites.
Ask the patient where does it hurt. Superficial
palpation in S shaped manner. Deep palpation in all
areas. Elicit tenderness, rigidity, guarding and palpate for
the organs e.g. liver, kidney, spleen, uterus, gallbladder
and aorto-iliac aneurysms.
Feel for ballottable organs/masses, fluid thrill, sacral
oedema.
Auscultation: Gut sounds whether normal, absent, increased
or tinkling
Friction rubs: Hepatic, splenic
Briuts: Renal, aortic, superior mesenteric and ileo-
femoral bruits.
Succussion splash.
Inguinal/femoral hernia: Ask the patient to cough, if not
obvious, then stands and coughs again.
Inspection: See overlying skin.
Cough impulse.
Palpation: Reduction by the patient

Tenderness
Cough impulse
Reducibility
Anatomical position of the neck of the hernia
Controllability
Inguinal/axillary and supraclavicular lymph nodes.
External genitalia
(Male) Draw scrotum on to the front of thighs
Inspection: Look for symmetry/skin/scars/rashes/
swellings i.e., inguinoscrotal, scrotal e.g., testicular and
epididymal)
Palpation: Testis, epididymis, spermatic cord
Relation of cyst/mass to testis
Penis Circumcisions, foreskin position, shape of
meatus, balanitis, discharge, rectal examination.
COMMANDS
Inspect this patients teeth
Palpate the liver
Palpate the spleen
Palpate the kidneys
Look for distended vessels
Examine for ascites
Look for shifting dullness
Elicit fluid thrill
Perform rectal examination.
COMMON COMMANDS
Inspect the Teeth
The Candidate
modesty.
6. Asks the patient to grimace to show teeth.
7. Asks to remove the dentures if worn.
8. Asks the patient to open the mouth widely.
9. Retracts the lips and cheeks to see the teeth.
10. Looks for tartar deposit, staining (beetle chewer,
tetracycline) horizontal bands, chalk white patches
due to flourosis with pitting and brown staining
(Maldens teeth).
11. Looks for shape of teeth, spacing in between (splaying
as in acromegaly), transverse ridging and other
abnormalities in shape.
examiner.
PEARLS
Breath of patient can also give enormous information. The
commonest is foul smelling breath called halitosis.
However, characteristic odours may also be recognized.
i. Sweet or fruity breath in ketosis.
ii. Fishy or ammoniacal smell in uraemia.
iii. Mousy smell in hepatic failure.
iv. Putrid smell in suppurative conditions of the lungs.
v. Stale apple smell in bronchiectasis.
vi. Paraldehyde and alcohol also have their own typical
odours.
PALPATE THE LIVER

The Candidate (See also Principles of Palpation on
Page 126)
6. Asks the patient to relax the abdominal wall and
instructs him to breathe quietly.
7. Starts from the right iliac fossa.
8. Uses the flat of right hand with the thumb tucked
under the palm, placing it parallel to the right sub-
costal margin.
9. Keeps index finger parallel to the costal margin.
10. Moulds the hand over abdominal wall.
11. Asks the patient to breathe in and out through his
mouth.
12. Tucks in his palm gently when the patient breathes
out.
13. Keeps it there during expiration.
14. Keeps it there during inspiration.

15. Feels the descending edge of an enlarged liver.
16. Tries to feel the border of liver which touches the index
finger.
17. Proceeds inch by inch upwards until he feels it.
18. Comments on size, margin, surface, consistency,
tenderness and pulsation of the liver.
19. Repeats this manoeuvre to the left of midline to detect
an enlarged left lobe of liver.
examiner.
PEARLS
It is important to locate upper border of liver by the method
of percussion.
OTHER METHODS TO PALPATE LIVER

Method 1
The Candidate
1. Stands on the right side of the patient facing the head
end of the patient.
6. Places finger tips of both hands joined together
parallel with the right costal margin.
7. Asks the patient to breath in and out.
8. Presses the abdominal wall inwards and upwards
during inspiration.
9. Feels for the descending liver edge during inspiration.

examiner.
Method 2
The Candidate
1. Stands on the right side of the patient and facing the
foot end of the patient.
modesty.
6. Places both his palms side by side.
7. Points the fingers towards inguinal region but parallel
to the costal margin.
8. Places the palm on right sub-costal area lateral to
rectus muscle.
9. Presses the tips of fingers inwards and upwards (i.e.
making a hook)
10. Asks the patient to breath in and out.
11. Tucks in during inspiration.
12. Feels the edge of the liver with pulps of the fingers.
13. Moves towards the mid line in epigastric area to feel
for left lobe of liver.
examiner.
Method 3
The Candidate
head end of the patient.
modesty.
6. Places palm of one hand parallel to the right rectus
muscle.
7. Feels for the movements of the liver edge under palm
with each cycle of respiration.
examiner.
PEARLS
This method is useful in those cases, where liver is not
palpable by classical method.
Method 4
The Candidate
head end of the patient.
modesty.

6. Begins with percussion below the sub-costal margin
downwards.
7. Notes the resonant area.
8. Palpates by classical methods below the percussed
lower border of liver dullness.
9. Continues towards the epigastrium for the left lobe
of liver.
examiner.
PEARLS
The candidate should comment as follows:
a. Whether liver is palpable or not.
b. Whether it is enlarged or displaced.
c. What is the extent of enlargement below the costal
margin? (Avoid using finger breadth as it varies from
person to person. Be precise by measuring the
maximum span with a measuring tape either in
centimetres or in inches in the mid clavicular line)
d. Comment on tenderness, surface whether smooth,
granular or nodular.
e. Comment on the margin (lower edge).
f. Whether enlargement is uniform.
g. Comment on the consistency i.e., soft, hard or firm.
Advice to the Reader

1. The patients abdomen should be completely relaxed
for a good abdominal examination, especially for
palpation of enlarged viscera.
2. For liver, begin from right iliac fossa upwards as it

is the direction, towards which liver enlarges. An
enlarged liver can be missed if its palpation is not
begun from the right iliac fossa.
3. Left lobe of the liver is normally palpable in the mid
line but hardly goes beyond the mid point between
xiphisternum and umbilicus.
4. Left lobe of liver should not be missed for an enlarged
xiphisternum or bulky tense recti muscle.
5. For enlarged gallbladder i.e. tumour or mucocoele etc.,
the patient should be rolled at 45 to the opposite side
to facilitate its palpation.
6. Murphys sign is elicited when the hand is placed at
gallbladder site and is pushed in when patient breathes
in resulting in pain and sudden holding of breath.
PALPATE THE SPLEEN (See also Principles of

Palpation on Page 126)
Spleen is again sub-diaphragmatic and enlarges from left
hypochondrium across the umbilicus to the right iliac fossa.
The spleen can be palpated by five methods:
Method 1
The Candidate
modesty.
6. Asks the patient to relax abdominal muscles.
7. Keeps the fingers of the right hand and palm in the
same plane.
8. Starts from the right iliac fossa.

9. Moves across the umbilicus and towards the left sub-
costal margin.
10. Keeps asking the patient to breathe in and out.
11. Lessens the inward pressure but maintains upward
pressure allowing fingers to drift in the direction of
descending spleen.
12. Feels for the border of spleen and the notch.
13. Turns the patient slightly towards right for easier
detection of spleen.
examiner.
Method 2
The Candidate
modesty.
6. Places left hand over the posterior aspect of the left
lower chest.
7. Turns the patient slightly towards right (towards
himself).
8. Exerts pressure from the back of the left side of chest
with his left hand in a forward direction.
9. Moves his right hand from right iliac fossa across
the umbilicus towards the left hypochondrium and
feels for the spleen.

examiner.
Method 3
The Candidate
modesty.
6. Tilts the patient slightly towards right side (towards
himself)
7. Asks the patient to place palm of his left hand under
his head (This will push up the left sub-costal margin)
8. Asks him to breathe deeply.
9. Feels for the splenic enlargement starting from right
iliac fossa across the umbilicus towards the left sub-
costal area.
examiner.
Method 4
The Candidate
1. Stands on the left side of the patient.

modesty.
6. Faces towards the foot end of the patient.
7. Places both palms together over the front of lower
chest.
8. Joins together the fingers.
9. Turns his finger tips inwards and upwards (making
a hook).
10. Asks the patient to breathe in and out.
11. Feels the spleen during inspiration.
examiner.
Method 5
Dipping method (in ascites)
The Candidate
modesty.
6. Pushes swiftly downwards in a jerky way with both
of his hands joined together.
7. Feels for the edge of floating spleen which is felt when
the fluid is displaced by dipping method.

examiner.
PEARLS
a. An enlarged spleen may be completely missed if not
palpated from right iliac fossa.
b. The normal splenic dullness should never extend
beyond the mid axillary line. Therefore, it is sometimes
important to percuss quickly afterwards by asking
permission from the examiner.
c. Splenic enlargement may be mild, moderate or severe.
Mild is when lower pole is less than half way to the
umbilicus or is 1-3 cm from the left costal margin.
Moderate is when lower pole is up to the level of the
umbilicus or is 3-7 cm from the left costal margin.
Severe is when lower pole is below the level of umbilicus
and is more than 7 cm from the left costal margin.
One should be able to differentiate between an enlarged
spleen and left kidney as it is sometimes very confusing.
Following is a table showing the differences between left
renal and splenic swellings.
Enlarged Spleen Enlarged (L) Kidney

1. Renal angle is not full. 1. Renal angle is full.
2. Bimanually not palpable. 2. Bimanually palpable.
3. Not ballotable 3. Ballotable
4. Enlarges towards right 4. Enlarges vertically up and
spinoumbilicus line. down may be forward.
5. Notch is felt. 5. No notch is felt.
6. No tenderness in renal angle. 6. Tenderness is in renal angle.
7. Moves with respiration. 7. Does not move or moves very
little.
Contd...
Contd...
Enlarged Spleen Enlarged (L) Kidney
8. Fingers cannot be insinuated 8. Can be insinuated.
between costal margin and
spleen.
9. Poles are angular. 9. Poles are rounded.
10. Finger can be dipped 10. Cannot dip the fingers.
between renal angles.
11. Bulge in the left 11. Bulge in the loin.
hypochondrium
12. Situated superficially. 12. Situated deeply.
13. Renal angle is resonant. 13. Renal angle is dull.
14. Dullness on percussion. 14. Resonant on percussion as
descending colon is lying
anteriorly.
Palpate the Kidneys (Bimanual palpation) (See also

Principles of Palpation on Pages 126 and 128)
The Candidate
modesty.
4. Makes sure that the light is adequate and natural.
6. Makes the patient lie down in supine position close
to the edge of the bed.
7. For palpation of right kidney:
i. Tucks in the left hand posteriorly in the right lumbar
area.
ii. Places the tips of the fingers of left hand in the
right renal area.
iii. Places the right hand with stretched palm and

fingers anteriorly over the right lumbar region below
the right costal margin at right angle to the margin
and lateral to the right rectus muscle.
iv. Asks the patient to breathe in deeply.
v. Presses fingers of both hands together finally and
attempt to catch the lower pole as it descends down
between two hands during inspiration.
8. For palpation of left kidney:
i. Tucks in his left hands palmar surface posteriorly
in the left flank.
ii. Places the fingers of the curved left hand in the
left renal angle.
iii. Places middle three fingers of the right hand below
the left costal margin lateral to the left rectus at a
point opposite the left hand.
iv. Presses both hands towards each other and ask the
patient to breathe in deeply.
v. Feels the lower pole of left kidney slipping between
the hands or the enlarged kidney.
examiner.
Examine this Patient for Ascites

The Candidate
modesty.
4. Makes sure that the light is adequate and natural.
6. Makes the patient lie down in supine position.

7. Moves towards the foot end of the bed and observes
the fullness of the flanks.
8. Notes the shape and position of the umbilicus.
9. Asks about any pain in abdomen.
10. Starts percussion from the epigastrium.
11. Comes down to umbilicus area in the mid line.
12. Moves gradually to each flank by placing pleximeter
finger parallel to the dull edge by a distance, each
of two centimetres. e.g., left flank.
13. Keeps the pleximeter finger there.
14. Turns the patient to the opposite side at 45 for a
few seconds i.e., right side.
15. Keeps on percussing to the same side i.e., left side
(Notes for resonant area which was dull before).
16. Keeps percussing back to the umbilicus i.e., right side.
17. Notes area of dullness again.
18. Asks the patient to turn towards opposite side at 45
(now the left side).
19. Waits for a few seconds.
20. Keeps percussing towards right side until it becomes
resonant.
21. Performs fluid thrill in case of tense ascites.
22. Asks the patient to put ulnar border of his right or
left hand in the centre of abdomen and press slightly.
23. Places left hand over patients left flank with
moderate pressure.
24. Taps the right flank with a flick of right index finger
and thumb to set up vibration.
25. Feels the vibration with the palm of left hand in the
left flank.
examiner.
PEARLS
a. Performs the dipping method for palpation of any
visceromegaly as it displaces the fluid by a forceful
jerk and the underlying organ hits the finger. This
needs a lot of expertise.
b. In eliciting fluid thrill, the patients hand is placed
over his abdomen for damping the conduction of
vibration through the abdominal fat.
c. While performing shifting dullness, a few seconds wait
results in shifting of fluid to the opposite side but more
importantly one has to wait for the air distended small
bowel to come up to produce resonance in a previously
dull area.
d. Fluid thrill and shifting dullness may be absent in very
massive or tense ascites.
e. Continuous dullness over flanks, iliac fossae, hypo-
gastric area with resonance over umbilical and
epigastric area is called horse shoe shaped dullness.
f. In minimum ascites, it is difficult to detect ascites or
dullness in supine position. However, in knee chest
position or knee elbow position, the umbilical area
becomes dull on percussion (puddle sign) but it is very
inconvenient and difficult.
g. In mild ascites flanks are full, horse shoe shaped
dullness is absent, shifting dullness is present but fluid
thrill is absent.
h. In moderate ascites, flanks are full, horse shoe shaped
dullness is present, shifting dullness is present but
fluid thrill is absent.
i. In massive ascites flank are bulged, whole abdomen is
dull to percussion, shifting dullness is absent but fluid
thrill is present.
j. At least 1500 millilitres of ascitic fluid must be present
for shifting dullness to be elicited.
k. Fluid thrill indicates that ascitic fluid is under tension

and is usually more than 1500 millilitres.
l. In gross ascites the epigastrium is tympanitic, in large
ovarian cyst or distended bladder the hypogastric area
is dull and there is no shifting dullness and the areas
in the lumbar and epigastrium are tympanitic. In intes-
tinal obstruction, the whole abdomen is tympanitic.
m. Position of umbilicus and its shape is important. In
ascites, it is displaced downwards and may be flat or
bulged or like a slit in horizontal direction. In large
ovarian cyst it may be displaced upwards and may
be of normal shape. In intestinal obstruction it may
be flat but not displaced in any direction.
Perform Ballottement (See also Bimanual

Palpation of Kidneys on Pages 126 and 128)
It is usually done for renal enlargement/masses.
The Candidate
6. Places left hand behind the right lumbar area for right
kidney.
7. Places the right hand over the front of right lumbar
area.
8. Places finger tips of the right hand just lateral to the
right rectus muscle.
9. Applies steady pressure with right hand posteriorly.
10. Pushes the swelling with his left hand upwards.
11. Feels the renal mass striking the right hand.

examiner.
PEARLS
Ballottement is typical feature of kidney enlargement.
Examine the Engorged Abdominal Veins and

Determine the Flow of Blood
The Candidate
modesty.
6. Asks the patient to stand upright if he can stand but
if not then asks the patient to lie down on the couch.
7. Exposes the abdomen quite well.
8. Chooses a segment of vein without any tributary.
9. Places index fingers or thumbs of right and left hands
parallel over that segment and milks out the vein for
a length of 3-5 cm.
10. Lifts one finger and observes the filling of vein.
11. Replaces the first finger and lifts up the second finger
and looks for the filling if no filling occurred in
previous step.
examiner.
PEARLS
a. In standing position the abdominal veins become more
prominent due to gravity as compared to supine
position.
b. One can use two tongue depressors in stead of index
fingers or thumbs of either hand.
c. The direction in which the vein fills in a faster speed
is the direction of flow of blood.
d. If the segment chosen has tributaries, the milked out
segment can be filled by them or cannot be milked out
satisfactorily. Therefore make sure that the segment of
vein chosen has no tributaries.
e. Venous hum is often heard over the portal collaterals
whereas it is usually absent over vena caval collaterals.
f. In normal persons, the abdominal veins are not visible.
g. In normal subjects the blood flow is away from the
umbilicus.
h. There is no rule that which finger should be taken away
or lifted up first.
i. Direction of blood flow should be determined above
and below the level of umbilicus.
j. Normal blood flow is vertically above and below the
umbilicus.
k. In portal hypertension, the distended vein radiate all
round the umbilicus towards the periphery called caput
medussae. However, in obstruction of the inferior vena
cava, the flow is from below the umbilicus upwards
in oblique tributaries which may be tortuous.
Perform a Digital Rectal Examination

Explain the procedure to the patient first as some patients
may refuse to undergo rectal examination.
The Candidate
modesty.
6. Makes him lie down in the left lateral position. Buttock
should project over the side of the couch.
7. Asks the patient to draw his right knee upwards close
to his abdomen while keeping left leg straight.
8. Puts gloves on both hands (preferred).
9. Stands behind the patients buttocks facing his feet.
10. Separates the buttocks gently and inspect the anus
and peri-anal area.
11. Asks the patient to bear down to see any prolapse
of piles or mucosa of anal canal.
12. Lubricates the index finger of right hand with
lubricant jelly.
13. Places the pulp of the right index at anus (Does not
insert the tip yet).
14. Puts the left hand on right buttock and presses his
lubricated finger firmly and slowly in a backward
direction.
15. Feels the tone of anal sphincter.
16. Pushes the finger forwards and sweeps around in
an anticlock wise direction up to 180 also pronating
the wrist to examine anterior part of rectum including
the prostate.
17. Notes the size, consistency, mobility, median sulcus
and mobility of mucosa over the prostate.
18. Rotates the finger clock wise to examine the right side
of the pelvis and asks the patient to strain.
19. Places the left hand over the suprapubic area and
presses it backwards for bimanual palpation (if
indicated).
20. Withdraws the finger.
21. Looks for any mucus, pus or blood on the finger.
22. Wipes the patient clean.
23. Tells the patient that examination is over.
examiner.
PEARLS
a. Careful inspection of anal area can give a lot of
information.
b. During palpation, resistance at anal sphincter can
easily be over come by asking the patient to strain as
if daefecating.
c. Tone of anal sphincter can be appreciated by asking
the patient to contract the anus.
d. Anus and rectum are empty in a normal person.
e. Push the finger about 2, 5 and 8 cm inwards until it
cannot be pushed at all.
f. In women, either the cervix is felt or more anteriorly
the fundus of a retroverted uterus, fibroid, ovarian cyst
or a pelvic abscess can be felt.
g. If in doubt, wipe the finger on a white gauze piece
or swab to see the type of discharge from the rectum.
CHAPTER 9
Examination of
Genitourinary
System
A set examination of genitourinary system is not routinely

performed. However, if renal disease is suspected by
history then certain signs must be sought.
The basic principles of inspection, palpation,
percussion and auscultation also apply during the
examination of this system. Few of the steps in this
examination are similar to that of abdominal examination
with special importance and concentration on kidneys.
CHECK LIST FOR NEPHROLOGICAL EXAMINATION

(FOR LONG CASES)
The Candidate
light is adequate.
recognition of people around, etc.
5. Examines the patient as a whole (stature, cushingoid
appearance, renal osteodystrophy, deformity, mousy
odour, lipodystrophy, acidotic breathing).
6. Examines the skin for (skin turgor, texture, pigmenta-
tion, scratch marks, angiokeratoma, vasculitis, butter-
fly or other rashes, cellulitis, xanthomata, herpes,
Kaposis sarcoma, uraemic frost, scabies, spiders,
tattooing)
7. Examines body hair, feels the texture and looks for
hair distribution (alopecia, hypertrichosis).
8. Examines and compares both hands (obvious
deformity, tremors, short metacarpals, ulnar deviation,
joint deformity, carpal tunnel syndrome, Dupuytrens
EXAMINATION OF GENITOURINARY SYSTEM 159
contracture, wasting, palmer erythema, Oslers nodes,

Janeways lesions, and oedema).
9. Examines the nails (polished nails, Muehrekes lines,
Beaus lines, leuconychia, reversal of nail pattern, two
tone nails, onychomycosis, onycholysis)
10. Checks for clubbing.
11. Records pulse compares pulses, checks for radio-
femoral delay, respiratory rate, and blood pressure
in supine position.
12. Examines forearms and arms for arteriovenous
fistulae.
13. Performs Allens test if patient is a candidate for
arteriovenous fistula.
14. Examines face for (deformity, asymmetry, cushingoid
facies, butterfly rash, pigmentation, and temporal
vessels).
15. Examines eyes with a torch (periorbital oedema,
xanthelasma, ptosis, arcus, jaundice, anaemia, band
keratopathy, keratoconus, squint, pupils, cataracts,
fundoscopy).
16. Examines nose (herpes nasolabialis, nasal deformity
Wageners granulomatosis)
17. Examines lips, mouth and oral cavity with a torch
and tongue depressor and instructs the patient
properly (orodental hygiene, oral thrush, angular
stomatitis, perioral pigmentation, tongue and its
under surface, mucosa, gums, teeth, tonsils, palate
and pharynx)
18. Checks ears for (hearing, tophi, deformity).
19. Examines the neck for (JVP, Kussmauls sign, engorged
neck vein, thyroid, lymph nodes)
20. Positions the patient comfortably and correctly and
exposes the entire abdomen.
21. Inspects the abdomen generally (peristalsis, fullness

in flanks (polycystic kidneys) and looks for operation
scars, peritoneal dialysis, catheter placement scars
etc.)
22. Notes type of respiration and movement of abdominal
wall and counts the respiratory rate.
23. Checks for integrity of recti.
24. Examines external genitalia for (varicocoele),
hydrocoele, patent processus vaginalis, hernial
orifices.
25. Performs light palpation in S shaped manner.
26. Palpates liver, spleen, urinary bladder and kidneys
(bimanually).
27. Palpates deeply for masses, colon, and glands.
28. Percusses for liver, splenic and urinary bladder
dullness.
29. Percusses for fluid thrill, shifting dullness etc.
30. Auscultates for renal artery bruit, venous hum, and
bowel sounds.
31. Examines lower limbs for (oedema, rashes, ulcers,
varicose veins, peripheral pulses).
32. Records blood pressure in lower limbs. (if necessary)
33. Records blood pressure in sitting position. (if
necessary)
34. Inspects the back (looks for swelling in renal areas,
spinal deformity).
35. Elicits any spinal or renal angle tenderness.
36. Notes for sacral oedema and auscultates lung bases
for fluid overload.
37. Examines axillae for dehydration, temperature record
and axillary lymph nodes
38. Examines for caput medusae, varicocoele and hernias
in standing position.
39. Cheeks pulse and blood pressure in standing position
for any postural hypotension.
40. Measures weight and height if required.

41. Examines gait if required.
42. Takes permission and performs rectal examination,
assesses for prostate size and its consistency.
43. Instructs the patient to put on clothes and helps him
if necessary.
to dress-up and helps him if necessary.
CASE WRITING TIPS

General appearance.
Look for:
Hyperventilation
Hiccup
Uraemic fetor (mousy smell)
Sallow complexion (dirty brown appearance)
Twitching (myoclonic jerks).
The hands
Examine nails for:
Muehrckes bands (paired white transverse lines
near end of nails)
Half and half nails, or Terrys nails (at least 1 mm
distal brown arc)
Mees lines (a single transverse white band)
Beauss lines (non-pigmented indented transverse
bands)
Shiny nails (due to scratching).
Examine palms for:
Palmar crease pallor
Asterixis.
Examine wrist and forearm for:
Surgically created arterio-venous fistula
Scars from previous failed fistula or carpel tunnel

syndrome surgery
Look for signs of carpal tunnel syndrome
Check pulse (supine)
Check blood pressure
Count respiratory rate
Check temperature.
The Arms:
Bruising
Skin pigmentation
Scratch marks
Uraemic frost
Purpuric vasculitic lesions
Tophi
Tendon xanthomata
Palpate axillae for dryness or wetness for hydration
status
The Face:
Examine eyes for:
Anaemia
Jaundice
Band keratopathy
Eyeball pressure for hydration status.
Examine mouth for:
Uraemic fetor
Mucosal ulcers
Thrush.
Examine face for:
Rash, skin tethering
Mask like face
Skin turgor.
The Neck:
JVP
Carotid bruit
Skin turgor over sternum for hydration status.
The legs and Feet:
Oedema
Purpura
Pigmentation
Scratch marks
Peripheral pulses.
The Abdominal Examination:
Inspection:
Roll the patient over and look in the region of loins
for nephrectomy scars
Inspect right or left iliac fossa for renal transplant
scar
Look in midline below umbilicus and lower
abdomen for scars of catheter placement used for
peritoneal dialysis
Distension because of large polycystic kidneys or
ascites
Inspect scrotum for masses and genital oedema
Palpation
Hepatosplenomegaly
Palpable kidneys
Distended bladder
Abdominal aortic aneurysm
Percussion
Ascites
Enlarged bladder
Auscultation
Renal bruit above umbilicus 2 cm to left or right
of midline
Rectal and pelvic examination:

Left varicocoele
Perform rectal examination for prostatic enlargement
The Back:
Strike the vertebral column with the base of fist to
elicit bony tenderness
Gently strike the fist over renal angle for tenderness
(Murphys punch)
Sacral oedema
Auscultate both flanks for renal bruit
The Chest:
Examine heart and lungs and look for signs of:
Congestive cardiac failure
Pericardial rub
Pleural effusion
Lung infection
The nervous system:
Examine legs and arms for:
Peripheral neuropathy
Myopathy
The fundi
Diabetic retinopathy
Hypertensive retinopathy.
CHAPTER 10
Examination
of Nervous
System
BASIC PRINCIPLES
A detailed examination of the nervous system can be very
lengthy and difficult to do at one sitting as it involves
different aspects of the system. Therefore it is necessary
to examine the nervous system step by step and to practice
this as much as possible.
Please bear in mind that it can be tiring and taxing
for the patient as well as for the examiner. If a patient
is tired after having gone through systemic examination
other than neurological examination, he may become non-
cooperative and mislead to the diagnosis.
Broadly speaking, the nervous system is divided into
the central, peripheral, and autonomic nervous system.
Diseases may affect single cortical area, cranial nerves,
peripheral nerves and spinal tract, alone or in combination,
thus leading to a variety of neurological deficits.
Localization of disease is helped by a precise history.
However, it is important to keep an open mind, as it is
easy to follow a wrong lead as to the level of the lesion
and there may be a possibility of disease at other levels
or multiple sites.
It is important to exactly note down the findings as
there is change in neurological signs and symptoms either
very shortly or over a long period of time. A well-recorded
history and neurological examination is very rewarding.
The most important questions in the neurological
examination include:
1. Where is the lesion?
2. What is the lesion?
The first impression of neurological function is
obtained by the posture, facies, gait, abnormal movements
and speech of the patient. A well-recorded history provides
clues to the temporal profile and possible aetiology of the
lesion.
EXAMINATION OF NERVOUS SYSTEM 167
If responses become erratic during examination it is

better to abandon examination and return later for re-
examination.
Always remember to turn the patient over when supine
to see any pathology over the back or spine. The muscles
of shoulders and pelvis should also be examined. As
already stressed, always record your findings in full and
avoid abbreviations e.g., SOMI for signs of meningeal
irritation, PERLA for pupils equal, reacting to light and
accommodation.
It is also advised to repeat the examination to look for
changing neurological signs.
NEUROLOGICAL EXAMINATION AS A WHOLE

(FOR LONG CASE)
The Candidate
light is adequate.
4. While doing this checks for higher mental functions
5. Examines the cranial nerves while the patient is sitting
up.
6. Checks olfactory nerve by testing smell in each nostril
separately, closing the nostril not being examined.
7. Checks optic nerve by testing visual acuity, visual
fields, fundoscopy, and colour vision.
8. Checks the pupils for their size, shape, reaction to
light both direct and consensual and accommodation
reaction.
9. Tests eye movements in all quadrants looking for
disconjugate gaze, strabismus and nystagmus and
asking for diplopia.
10. Tests sensation in ophthalmic, maxillary and
mandibular divisions of trigeminal nerves (sensory
part).
11. Asks the patient to open the mouth against resistance
and protrude and move the jaw from side to side.
Asks the patient to clench the teeth and checks
temporal and masseter muscles on each side (motor
part).
12. Checks corneal reflex properly (see later)
13. Instructs the patients to look up, to shut the eyes, to
smile and to inflate mouth for facial nerve (motor part)
14. Tests sensation of taste on anterior part of tongue.

[sensory part]
15. Tests hearing and performs Rinnes test and Webers
test (if indicated) with a tuning fork of frequency of
256 Hz.
16. Tests palatal movements, movement of the uvula and
palatal reflex for glosso pharyngeal and vagus nerve.
17. Examines the tongue while keeping it in the mouth,
asks to protrude the tongue and checks movements
in all directions for hypoglossal nerve.
18. Asks the patient to shrug the shoulders against
resistant and to move the neck side ways and forward
and upwards against resistance to check integrity of
accessory nerve.
19. Examines the upper limbs for bulk of the muscles
and abnormal movements, looks for fasciculations.
20. Assesses the tone of the muscles of the upper limbs.
21. Checks the jaw, biceps, triceps and supinator jerks.
22. Assesses the power of the muscles of upper limbs
actively and passively (proximally and distally),
grades the power properly (0-5).
23. Checks for coordination of movements by performing
finger nose test or tapping of the palms.
upper limbs.
25. Checks for position and vibration sensations (tuning
fork of 128 Hz).
26. Checks temperature sensation both hot and cold.
27. Elicits tactile localization and two point
discrimination.
28. Performs superficial reflexes i.e., abdominal and
cremesteric.
29. Inspects the bulk of muscles and any abnormal
movements in the lower limbs.
30. Assesses the tone of the muscles of lower limbs.

31. Assesses the power of the muscles of lower limbs both
actively and passively (proximally and distally)
grades the power properly (0-5).
32. Elicits clonus (grade 0-4).
33. Checks for knee jerk, ankle jerk and plantar responses.
34. Checks for coordination of movements in the lower
limbs by performing heel shin test.
lower limbs.
36. Checks for position and vibration sensations (tuning
fork 128 Hz).
37. Checks temperature sensation both hot and cold.
38. Elicits tactile localization and two point discrimi-
nation.
39. Elicits neck stiffness.
40. Performs Kernigs and Brudzinskis manoeuvre
looking for signs of meningeal irritation.
41. Examines gait, tandem walking and Rombergs test.
42. Checks for retropulsion and propulsion.
to dress-up and helps him if necessary and offers to
helps.
CASE WRITING TIPS

The neurological examination can easily be performed if
one adheres to the following guidelines: it is under 12
headings with sub-headings:
1. Higher mental functions
a. Level of consciousness
b. General behaviours
c. Intelligence
d. Memory
e. Orientation in place and time and person

f. Hallucinations and delusions
g. Emotional state
h. Insight.
2. Speech (Ask about right or left handedness)
a. Spontaneous speech
b. Comprehension of written commands
c. Naming of objects
d. Simple numerical calculation?
3. Cranial Nerves
I. Check smell, separate nostrils.
II. 1. Visual acuity
2. Visual fields
3. Fundoscopy.
III, IV, VI
1. Pupillary response to direct light consensual/
accommodation
2. Size of pupil, regularity
3. Enophthalmos
4. Exophthalmos
5. Ptosispartial or complete
6. Nystagmus
7. Extraocular movements.
V. 1. Motor partmuscles of mastication
2. Sensory part Sensation in ophthalmic,
maxillary and submandibular divisions
3. Corneal reflex
4. Jaw jerk.
VII. 1. Muscles of facial expression
2. Test hearing
3. Check anterior 2/3 of the tongue for taste.
VIII. (a) Auditory
1 Hearing tickling watch, scratch hair in front
of pinna
2 Rinnes test
3 Webers test
(b) Vestibular
Dix. Hall pike manoeuvre.
IX. 1. Say Aah
2. Gag reflex
3. Taste on the posterior 1/3 of tongue.
X. 1. Voice
2. Cough
3. Uvular deviation.
XI. 1. Shrugging of shoulders
2. Rotation of neck.
XII. 1. Tongue bulkwasting etc
2. Abnormal movements, fasciculations
3. Deviation of the tongue after protruding
4. Myotonia by percussing the tongue.
4. Motor System
a. BulkHypertrophy, wasting
b. ToneSpasticity, flaccidity, clonus, rigidity
c. PowerHand grip
d. Coordinationfinger nose, heel shin test,
dysdiadochokinesia
e. Involuntary (abnormal) movements e.g., tremors,
fasciculations, choreiform movements, athetoid
movements, convulsions, ticks
f. Reflexes
g. Gait (some includes in motor system, it has been
discussed under separate headings).
5. Sensory System
Nerve root level
Spinal cord level
Hemi-anaesthesia.
A. Superficial
Light touch cotton wool
Pain pinprick
Temperature finger, tuning fork, test tubes with

hot and cold water.
B. Deep
Vibrationstart distally
Position of joints hold sides of the digits
Position of limbs should place other limb in the
same position or tell if unable to move the other
limb as well
C. Cortical
Tactile localization use callipers
Tactile discrimination use compass
Stereognosis use coins or keys.
6. Reflexes
A. Superficial:
1. Corneal and conjunctival
2. Palatal
3. Pharyngeal
4. Abdominal
Upper
Middle
Lower
5. Cremesteric in males
6. Plantar
B. Deep:
1. Face (jaw jerk)
2. Upper limb (biceps, triceps and supinator jerks)
3. Lower limb (knee and ankle jerks).
C. Organic reflexes:
1. Micturition
2. Defaecation
3. Deglutition
4. Respiration
D. Primitive reflexes:
1. Glabellar tap
2. Palmomental
3. Moros reflex
4. Pout and snout
7. Signs of Meningeal Irritation
1 Neck stiffness
2 Brudzinskis neck sign
3 Brudzinskis leg sign
4 Kernigs sign
8. Cerebellar Signs
1. Nystagmus
2. Speech
3. Tone
4. Coordination
5. Disdiadochokinesia
6. Rebound phenomenon
7. Pendular jerks
8. Gait.
9. Spine and Skull
1. Scar
2. Deformity
3. Tenderness in spine.
10. Gait
All types
1. Festinant
2. Hemiplegic
3. Stamping
4. Ataxic
5. Shuffling
6. Spastic
7. Cerebellar
8. Waddling
9. Ataxia abasia
10. Hysterical.
11. Fundoscopic Examination

1. Retinoscopy
2. Proper fundus examination.
12. Carotid Atresia/Stenosis for bruits
13. Cardiovascular Auscultation for Atrial Fibrillation
14. Autonomic Nervous System
1. Sweating
2. Postural hypotension
3. Heart rate response to Valsalvas manoeuvre.
15. Abnormal Peripheral Nerve thickening,
neurofibromata
16. Neuropathic, Disorganized Joints Charcots joints.
COMMON COMMANDS (SHORT CASES)

How would you check the level of consciousness?
The Candidate
3. Does a general survey of the patient and notes if he
is fully alert and conscious.
4. Calls the patient with his name and tries to converse.
5. Notes whether the patient opens his eye, and talks
relevant (Verbal stimuli are responded verbally).
6. Checks whether patient is stuporosed by arousing
him with painful stimuli.
7. Observes the response of patient by verbal commands.
Notes any restlessness or spontaneous movements.
8. Checks whether patient is semi-comatosed by exerting
painful stimuli or shaking him and notes any
withdrawal of any part by the patient and any
grimaces or other movements.
9. Notes any muttering by the patient.
10. Checks for coma by deep painful stimuli or any other
kind of stimuli and notes any response (Usually very
minimal response).
examiner.
How would you check memory of the patient?

The Candidate
modesty.

6. Checks short term memory by showing a sequence
of objects e.g., pen, paper, watch, coin etc.
7. Asks the patient to repeat in the same sequence after
a minute.
8. Asks to repeat 7 numbered digits after a minute.
9. Asks him to tell five digits backwards.
10. Checks recent memory by asking what the patient
had this morning to eat, todays news if he had read
the newspaper and duration of illness in days.
11. Checks long term memory by asking his date of birth
or date of wedding or by asking him the name of
his school or college.
12. Notes down all the relevant information in this
context.
examiner.
How would you check the speech?

The Candidate
modesty.
6. Asks him whether he is right handed or left handed.
7. Observe spontaneous speech and notes its type.
8. Gives verbal commands to do little manoeuvres e.g.,
to open the month, to put the tongue out, to touch
the nose, etc.
9. Gives written commands to lift up his hands or show

his teeth.
10. Asks the patient to read aloud from the book.
11. Asks the patient to write as per dictation.
12. Asks the patient to name objects e.g., pen, pencil or
a book.
13. Asks him to calculate simple numerical problems.
examiner.
PEARLS
1. Dysarthria is inability to pronounce due to defect in
the articulating muscles. Before diagnosing this, local
causes e.g., edentulous state, tongue tie etc., should be
excluded.
2. Dysphasia is due to defective function due to diseases
of the speech centre.
3. In motor dysphasia (expressive) patient is able to
understand but unable to express.
4. In sensory aphasia (receptive), the patient does not
understand but can speak otherwise.
5. In patient with global aphasia, he is unable to
understand or speak either.
Check the Patient for Apraxia

The Candidate
modesty.

6. Confirms that the patient can understand whatever
you say.
7. Confirms intact motor, sensory and cerebellar
functions.
8. Confirms the right or left handedness of the patient.
9. Checks construction apraxia by asking him to make
a square from match sticks.
10. Checks dressing apraxia by asking him to unbutton
his shirt or remove the shirt.
11. Notes whether these defects are unilateral or bilateral.
examiner.
PEARLS
1. In ideational apraxia, the patient has no concept to
use the object or objects for a task.
2. In ideomotor apraxia, the concept is present but motor
function is not there to carry out that particular idea.
Check the Patient for Agnosia

The Candidate
5. Confirms that motor sensory and cerebellar functions
are intact.
6. To check visual agnosia, asks the patient to walk till

the door and then asks him to come back. Asks the
patient to name common objects when shown to him.
Asks the patient to tell the different colours of the
objects when shown to him.
7. To check tactile agnosia, asks the patient to close his
eyes and try to recognize objects by touching or feeling
them e.g., coins, keys, pen, watch etc.
8. To check auditory agnosia, asks the patient to close
his eyes and to recognize different sounds i.e., shaking
of coins, tinkling of water, ringing of bell or ticking
of a watch.
9. Asks questions i.e., which is the index finger, right
or left etc to check whether patient can recognize his
own body, either right or left side.
10. Check whether these defects are unilateral or bilateral.
examiner.
PEARLS
a. When there is denial of illness in its extreme form it
is called anosognosia.
b. Constructional agnosia includes inability to draw a
figure or construct an object or map the surroundings.
c. Inability to recognize faces is called prosopagnosia.
d. In visual agnosia, one can ask the patient to manipulate
the objects a little bit to see if the recognition is
improved.
CRANIAL NERVES
Both right and left cranial nerves should be examined
separately and the finding should be compared.
Olfactory Nerve
This nerve is not so commonly tested although the
examination starts from this nerve.
The Candidate
modesty.
6. Uses common materials for testing the sense of smell
i.e., soap, tooth paste, lemon, spirit, etc.
7. Asks the patient to close his eyes.
8. Asks the patient to close his one nostril.
9. Brings forward the material to be smelled and asks
the patient to take a couple of good sniffs.
10. Asks him whether he can smell or not.
11. Asks the patient to identify the smell and makes a
note of its correctness.
12. Tests the other nostril in the same way.
13. Helps the patient redressing.( if wearing a veil)
examiner.
PEARLS
a. Do not use pungent odours like ammonia, ether, vinegar
as these can stimulate trigeminal nerve.
b. It is better to test one nostril at one time. The patient
is asked to sniff through the nostril to be tested. Make
sure that it is patent and then place the odour to be
tested under the nostril.
c. Some patients cannot name the odour in particular but
they do recognize it. This is sufficient as well.
d. The interval between the different odours to be tested
should be sufficient enough so that the previous odour
should disappear by the time second odour is tested.
e. In anosmia, there is complete absence of sense of smell.
f. In parosmia pleasant odours seem offensive and foul
smelling.
g. In temporal lobe epilepsy one can get olfactory
hallucinations.
h. Candidate should know a check list of causes of
anosmia.
Optic Nerve
The optic nerve is not a simple nerve to examine and the
candidate has to examine their important components,
which are as follows:
i Visual acuity (VA)
ii Field of vision
iii Colour vision
The visual acuity is very vital step but if the patient
is blind, then there will be no point to test for field of
vision and colour vision.
Visual Acuity (VA)
For far vision Snellens chart is used but finger counting
method is also useful.
The Candidate
modesty.(especially if the patient is wearing a veil)
5. Asks the patient to cover one eye with his hand on
the same side.
6. The candidate holds his own hand extended and
fingers abducted in front of the patients open
eye.
7. Starts asking him to count the fingers at a distance
of one foot and moves away asking him to count
the fingers (different numbers) and go up to six
meters.
8. If the fingers can not be seen by the patient even very
near to him, then determines whether the patient can
see hand movements (HM) or light perception (PL)
after showing him some light.
9. Tests near vision with Jaegers chart of different sizes
fonts.
10. Checks colour vision with Ishiharas chart.
11. Tests each eye separately.
12. Notes any abnormality and comments on that.
13. Helps the patient redressing ( if wearing a veil)
examiner.
PEARLS
Colour vision can also be tested with Holmgrens wool
or Farnsworth-Munsell coloured tiles.
Use alternative test type for illiterate people i.e., E test.
Snellens chart: The chart has 8 rows which can be seen

by a normal eye at 60, 36, 24, 18, 12, 8, 6 and 5 meters
respectively. The upper number is the distance of the
subject from the chart and it is usually 6 meters.
The lower number is the distance of the smallest line
that can be read easily. At 6 meters it is the 7th line, which
should be read at 6 meters as already mentioned, so the
VA will be 6/6. But if a subject can read only the 7st line
at 6 meters (which should be read at 60 meter) then the
visual acuity will be 6/60. If the VA is less than 6/60,
then the subject is moved towards the chart i.e., 3/60. If
the top line cannot be read at a distance of one meter i.e.,
worse than 1/60 then VA is reported as counting fingers
(CF), seeing hand movements (HM) or only perception of
light (PL).
Field of Vision
To elicit this, patient must be able to see the fingers from
a distance of at least 3 feet or one meter.
Ideally, the field of vision is measured by perimetry
but in the clinical set up in the wards, confrontation
method is applied. Following steps are to be followed:
The Candidate
4. Makes the patient sit opposite to him at the same
level about a meter apart.
5. Asks the patient to close his one eye e.g., left eye with
his left hand.
6. Asks the patient to look and focus his right eye on

his (candidates) left eye.
7. The candidate closes his right eye with his right palm
on the same side.
8. The candidate focuses his left eye on the patient right
eye ball for any movements. (The patient looks at
candidates opened eye and the candidate looks at
patients opened eye)
9. The candidate out stretches his left upper limb
laterally as far as possible midway between patient
and himself with index finger extended and other
fingers flexed.
10. The candidate wiggles his extended index finger and
brings his hand with the wiggling finger near the
patient.
11. Instructs the patient to tell immediately when the
index finger of the candidate is seen wiggling.
12. Makes sure that patients eye ball does not move or
follow the index finger of the candidate.
13. When the candidate sees wiggling index finger, the
patient should also be able to see it provided
candidates field of vision is normal.
14. The candidate tests this in all the directions or
quadrants.
15. Checks the field of vision of other eye in the same
manner.
16. Helps the patient redressing (if wearing a veil)
examiner.
PEARLS
a. Another crude method called Menace reflex is used
when the patient is not cooperative. In this method,
the patient is asked to look ahead and the examiner
brings palm of his hand rapidly towards the patient
in front of his face from one side. The patient blinks
reflexly. Examine each quadrant and also the other eye
in a similar way.
b. One should move finger from blind area to area of
vision.
c. A wiggling or moving finger is easily appreciated than
a static finger.
d. One can use a red, white or green coloured hat pins
in turn. The visual fields for coloured objects are smaller
than for white objects. They are useful to plot scotomas.
e Visual inattention defects are assessed by the examiner
moving fingers of both hands separately or together
and the subject is asked to identify which finger is
moving. Examiners both upper limbs are out stretched
horizontally but in opposite directions. Visual field on
average extends about 100 outwards (temporally), 60o
degree upward (superiorly), 60 inwards (nasally) and
75 downwards (inferiorly).
f A more precise method of mapping of the peripheral
fields is by perimetry.
g Alternatively, a Bjerrum screen is used with a white
or red disc being moved radially inwards against a
black background. Loss of parts of visual fields called
scotomas can easily be mapped out. Therefore,
assessment can be made as far as damage to optic nerve,
optic chiasma, optic tract and optic radiation.
h. Colour Vision: In the wards, a simple method may be
used i.e., showing objects of different colours e.g., book,
pen, clothes, neck tie to the patient and then ask about
the colour. Both eyes should be tested separately. Red,

green and blue colours are called primary colours.
Normal colour vision is declared if the patient is able
to identify these colours.
CHECK LIGHT AND ACCOMMODATION REFLEXES

Light Reflex
The Candidate
(especially if the patient is wearing a veil).
3. Patient should be in a shade or indirectly illuminated
room.
4. Examines each eye separately.
5. Asks the patient to look into distance to relax
accommodation.
6. Shines a bright light into one eye.
7. Observes papillary constriction and notes that it
immediately relaxes (dilates) and after a few
contractions settles down to a smaller size.
8. Observes that switching of light dilates the pupil
which goes back to its original size.
9. Tests the consensual light reflex by keeping one eye
in shade while shining light into other eye (puts his
stretched hand vertically over the patients bridge of
the nose).
10. Observes the pupil of non-illuminated eye.
11. Helps the patient redressing.(if wearing a veil)
examiner.
PEARLS
a. In optic neuritis Gunn pupil is observed which is due
to an afferent defect i.e., lesion in optic nerve.
b. Wernicke pupil reaction though is difficult to elicit,
involves less active papillary light reaction when the
beam is shown from the hemi-anopic side, than when
shown from normal side.
Accommodation Reflex
The Candidate
(especially if the patient is wearing a veil).
4. Asks the patient to hold his head straight.
5. The candidate holds his index finger close to
patients nose.
6. Asks him to look far away from it.
7. Asks him to look quickly at the finger (it is better to
lift the eye brows for a good response).
8. Notes the convergence of the eyes.
9. Notes that the pupils also constrict.
10. Asks the patient to hold his finger about 30 cm in
front of his face if his vision is impaired.
11. Asks him to look at the finger.
12. Notes convergence of eye balls and constriction of
the pupils.
13. Helps the patient redressing (if wearing a veil).
examiner.
PEARLS
a. Argyll Robertsons pupil is a classical papillary
abnormality of neurosyphilis. The pupil is small,
irregular; it does react briskly to accommodation but
does not react to light. The response of pupil to
mydriatics is slow. One side may be involved more
than the other. The lesion is in the pretectal region of
the mesencephalon.
b. Adies pupil or tonic pupil has absent or delayed
papillary constriction to light and accommodation.
Once constricted it dilates slowly. It varies in size
during the day, time to time but never reacts promptly
to light. It is associated with absent tendon reflexes
often on the same side as the papillary abnormality
called Holmes-Adie syndrome.
c. Candidate should know various types of papillary
characters, features of Horners syndrome, different
causes of small and large pupils and other associated
conditions.
Examine this Patient for Squint

The Candidate
(especially if the patient is wearing a veil)
4. Places an object about a meter in front of the patient.
5. Asks the patient to look at this object with both eyes.
6. Looks at the patient for any obvious squint (primary
deviation).
7. Covers the patients eye which is apparently fixing.
8. Looks for any deviation of the uncovered eye and

notes any movement of the eye trying to fixate.
9. Shifts the cover to the other eye.
10. Looks for any deviation of the uncovered eye making
any movement in taking up fixation (secondary
deviation).
11. Moves and shift the cover quickly from one eye to
other eye to confirm findings.
12. Helps the patient redressing. (if wearing a veil)
examiner.
PEARLS
a. In case of paralytic squint, diplopia occurs. However,
no paralytic squint usually occurs in childhood and
is due to a lazy eye unable to focus at any object due
to some pathology in the retina or due to refractive
error.
b. Primary deviation is the deviation of the paralysed
muscle where as secondary deviation is the deviation
of non-paralysed muscle. Primary deviation is equal
to secondary deviation in non-paralysed squint.
Perform Fundoscopic Examination

Or
Look into this patients fundus
Or
Perform ophthalmoscopy
(Explain the procedure to the patient)
The Candidate

3. Makes sure the examination is done in a darkened
environment.
4. Uses mydriatics before the examination. (firstly rule
out close angle glaucoma)
5. Asks the patient to look straight ahead and fix both
his eye on a selected distant object.
6. Holds the ophthalmoscope in his right hand with
its lens at 0 and places in front of his right eye,
as close as possible pressing it at the side of nose
and superior orbital margin and with the index finger
over the lens rotator.
7. Places his left hand over the head of the patient with
left thumb, elevating the right eye brow of the patient
and also holding the head.
8. Switches on the light of ophthalmoscope.
9. Starts examination at a distance of about 20-30 cm
away from patients eye.
10. Performs slight twisting movements of the
ophthalmoscope to see a red reflex (any opacity in
the field will look dark).
11. Proceeds close to the patients eye seeing the red reflex.
12. Comes as close to the patient as possible without
touching his eye lashes or cornea.
13. Looks at the retinal blood vessels and notes its
character.
14. Looks in all four quadrants by slightly angulating
the head of ophthalmoscope.
15. Moves the lens of rotator to focus clearly on the
fundus.
16. Looks carefully on the disc and its margins.
17. Asks the patient to look directly into the light of
ophthalmoscope and observes the macula.
18. Examines both eyes in turn.

21. Make notes of the abnormalities and comments on
optic disc, retinal arteries, veins, background of retina
and macula and any other abnormal findings while
PEARLS
a. The rule of thumb for ophthalmoscopic examination
is simple i.e., for patients right eye, the examiner uses
his right eye and holds the ophthalmoscope in his right
hand and for examination of left eye of the patient,
holds the ophthalmoscope in his left hand and uses
his left eye. This procedure will avoid any direct contact
of the face of examiner with that of the patient and
therefore would not breathe directly into his face which
can be very irritating to patient as well as to the
examiner. This also allows the patient to see far away
with his unobstructed eye so that the pupils remain
relaxed.
b. If lenses are numbered in black they are positive lenses
(convex) and indicate hypermetropia, if the lenses are
numbered in red they are negative lenses (concave) and
indicate myopia.
Examine Ocular Movements

The command actually tests the oculomotor (3rd), trochlear
(4th) and abducent (6th) cranial nerve simultaneously.
They all supply the extraocular muscles which rotate the
eyeballs in different directions.
These nerves are tested as follows to elicit.
i. Movements of eyeball
ii. Nystagmus
iii. Ptosis
iv. Size and shape of the pupils
Reaction to light (direct and consensual) and to
accommodation has already been discussed previously (See
on page 187).
The Candidate
1. Stands in front of the patient.
6. Asks for any history of diplopia.
7. Fixes the patients head and asks him to look far
away.
8. Stabilizes the head of the patient in the centre by
holding it with his left hand placed over the vertex.
9. Holds the right index finger about a foots distance
in front of the patients eye.
10. Notes any squint obviously present in resting
position.
11. Notes the papillary size.
12. Notes for the presence of ptosis.
13. Instructs the patient to follow the finger when it moves
without moving his head.
14. Moves the finger horizontally to either direction i.e.,
right and left.
15. Moves the finger upward and downwards when the
eyes are either adducted or abducted (sometimes
nystagmus can be seen as well).
16. Checks separately each eye.
17. Checks both eyes simultaneously.

18. Helps the patient re-dressing.( if wearing a veil)
20. Comments on any abnormal findings.
PEARLS
a. Do not adduct or abduct eyes to extremes as
spontaneous nystagmus occurs normally.
b. Eye normally moves 50 medially, 30 upwards and
50 downwards.
c. Normal gaze is conjugate gaze i.e., both visual axis
move parallel.
d. Patient complains of diplopia when eye ball is turned
in the direction of action of weak muscle.
e. In third nerve palsy, eye ball is deviated downwards
and laterally with dilated pupil and partial or complete
ptosis.
f. In forth nerve paralysis medial deviation occurs.
g. In sixth nerve palsy, medial deviation occurs.
h. In 4th nerve palsy, adducted eye does not move
downwards and in sixth nerve palsy the eye does not
abduct fully.
i. See previous pages for examination of patient with
squint
Examination this Patient for Nystagmus

The Candidate
(in females wearing the veil).

6. Holds his index finger about 12 inches away in front
of the patients eyes.
7. Asks him to keep looking at his finger.
8. Looks for rhythmical movements of the eye balls if
nystagmus is present.
9. Moves the finger to the left and right, upwards and
downwards.
10. Maintains deviation on each side for at least
5 seconds.
11. Avoids deviation to the extreme of the lateral gaze.
12. Notes the presence of nystagmus or absence of
nystagmus.
13. Makes a note of nystagmus whether:
Horizontal, vertical or rotatory
Pendular or jerky
Direction of fast component
Severity of nystagmus
Possible aetiology of nystagmus.
PEARLS
a. Nystagmus cannot occur in a comatosed patient, as
it requires fixation of the eyes and a comatosed patient
cannot do that.
b. One should not hold the object either too close to too
extreme to the lateral sides, as it can lead to
spontaneous jerky movements.
c. It may take 5 seconds for nystagmus to occur. Therefore,
one should maintain deviation for at least 5 seconds.
d. The direction of the fast component is the direction

of the nystagmus.
e. Grading of nystagmus is done as follows:
First degree Occurs only on looking in the
direction of the fast component.
Second degree Occurs while looking straight
ahead.
Third degree Occurs even looking in the direction
of slow component.
f. Congenital nystagmus is associated with albinism.
g. Travellers nystagmus is seen during travelling in train
looking outside through the window while the train
is moving.
Examine the Trigeminal Nerve

It is a mixed nerve and has ophthalmic and maxillary
divisions which are sensory whereas mandibular division
is both sensory and motor. The examination of this nerve
comprises the following components:
Checking touch pain and temperature sensations in
the above three divisions.
1. Checking conjunctival and corneal reflexes.
2. Checking the muscles of mastication.
3. Eliciting jaw jerk (deep reflexes).
For conjunctival and corneal reflexes, ophthalmic
division is sensory and facial nerve is motor and closure
of the eyes is mediated by orbicularis occuli.
The Candidate
modesty (in females wearing the veil).

6. Checks symmetry of the temporal fossae.
7. Checks that angles of jaw are symmetrical.
8. Asks the patient to clench his teeth.
9. Palpates the temporalis muscles simultaneously.
10. Palpates the masseter muscles simultaneously.
11. Examines and compares both sides.
12. Asks the patient to open the mouth after placing hand
under his jaw and applying resistance upwards.
13. Places one hand on each side of the jaw of the patient
and asks him to move from side to side against
resistance to check for lateral pterygoid muscles.
14. Checks for jaw jerk (see details under reflexes on
page 266).
15. Takes a wisp of cotton for light touch.
16. Makes him feel the feeling of cotton wisp by lightly
touching on his forearm.
17. Asks him to shut his eyes.
18. Touches near the midline of forehead, upper front of
the sides of nose, malar region, upper lip, chin and
anterior 2/3 of the tongue.
19. Asks the patient to say yes when he feels it.
20. Compares with the opposite side simultaneously.
21. Similarly checks for pain sensation with a pin.
22. Checks for temperature sensation with warm and cold
water filled test tubes.
23. Avoids angle of the jaw while testing this.
24. Goes up to the vertex to check for ophthalmic division.
PEARLS
a. Avoid checking the trigeminal nerve in the midline as
the fibres cross on the opposite side as well.
b. Skin over the angle of jaw is supplied by second and
third cervical segments and not by trigeminal nerves.
c. Check all types of sensations i.e. touch, temperature
(hot and cold) and pain.
Check for Corneal Reflex

The Candidate
6. Uses a wisp of cotton wool (Better if moistened with
water).
7. Patient is asked to look at one side upwards and
inwards. (finger can be shown for this direction).
8. Brings cotton wisp from the outer (lateral) side.
9. Touches the cornea at its junction with conjunctiva.
10. Avoids touching eyelashes or eyelids.
11. Observes the positive reflex (Sudden closure of the
eye shows normal reflex).
12. Tests the other eye in the same way.
PEARLS
a. Avoid touching middle of the cornea as it can be
damaged thus resulting in serious visual impairment.
b. Alternately a puff of air can be used instead of a cotton
wisp.
c. Try to avoid patient seeing the cotton wisp approaching
to his eyes. If he sees it, reflex blinking can occur.
d. Wisp is moistened so as the avoid damage to the
cornea.
e. Corneal reflex is absent in 5-10% of normal subjects.
f. Blinking of eye being touched is called direct corneal
reflex and of the opposite eye is called consensual
corneal reflex.
Examine the Facial Nerve

The 7th nerve supplies the muscles of facial expression
and platysma except levator palpebrae superioris.
This nerve also has two parts. A motor part, which
supplies muscles of facial expression and the sensory part,
which carries taste sensations from the anterior 2/3 of
the tongue.
The Candidate
6. Inspects the face for any obvious asymmetry.
7. Inspects the wrinkles on the forehead.
8. Observes the nasolabial folds.
9. Looks at both palpebral fissures.

10. Observes any involuntary movements, excessive
lacrimation and salivation from either angle of the
mouth.
11. Asks the patient to wrinkle forehead and observe the
symmetry.
12. Asks the patient to shut his eyes and observes the
attempt to close eye and notes the upward rolling
of the eye ball on either side (Bells phenomenon).
13. Attempts to open the tightly closed eyes by his fingers
and notes which side opens easily.
14. Asks the patient to show the teeth and notes which
side the angle of mouth is deviated (non-paralysed
side)
15. Asks the patient to whistle.
16. Asks the patient to blow his mouth and while the
air is the patients mouth tries to push it with his
fingers from outside and notes which side it leaks
from.
17. Everts the lower lip and asks the patient to say eeee.
(This manoeuvre checks for platysma)
18. Notes down abnormalities and also inspects the back
of ear especially for any parotid swelling (extension)
or discharge, vesicles on the ear pinna and mastoid
area.
PEARLS
a. Candidate should differentiate between upper motor
neurone (UMN) and lower motor neurone (LMN)
lesions of facial nerve by interpreting wrinkles on
forehead and ability to close both eyes.
b. While asking patient to close his eyes, look at the angles

of mouth which are normally drawn upwards on both
sides.
c. In comatosed patient, during expiration air emerges
out from the angle of mouth on the paralysed side and
is an important sign to detect the side of paralysis in
an unconscious patient.
d. Bells phenomenon is present in LMN lesion.
e. It is important to test for lacrimation, salivation and
taste to know exactly the level of the lesion in cases
of LMN facial palsy.
f. Hyperacusis is due to paralysis of stapedius muscle.
g. In UMN the lower part of face is affected and forehead
is spared as it has bilateral cortical supply.
Check for Taste Sensation

The Candidate
6. Explains the procedure to the patient.
7. Uses solution of salt, sugar, and vinegar.
8. Asks the patient to protrude his tongue.
9. Holds the tip of the tongue with a sterile gauze piece.
10. Applies the solution on the side of the tongue about
an inch behind the tip.
11. Instructs the patient not to speak but raise the index
finger if he tastes sweet, middle finger if bitter and
thumb if saltish taste is experienced.
12. Asks the patient to rinse the mouth with water after
testing with each taste (Quinine is applied in the end
to check bitter taste).
13. Both sides are examined and compared and
comments are made.
PEARLS
1. While testing the taste, patient should not speak as
when he speaks, the pooled saliva will spread the
solution to be tested on both sides.
2. Bitter taste is tested in the end as its effect lasts longer.
3. Loss of taste is called ageusia and the lesion can be
any where from tongue to the central course of fibres.
Check the Auditory Part of Eight Nerve

Eight nerve has two parts, the auditory component and
the vestibular component. The former is for hearing and
the later is for keeping equilibrium of eyes, head and body.
The Cochlear Part of 8th Nerve

The Candidate
modesty.(in females wearing the veil)
4. Makes sure the light is adequate and natural and
there is no noisy surrounding atmosphere.
6. Makes sure that the external auditory meatus is free

of wax and fungus ball.
7. Tests one ear at one time while the other ear is tightly
closed.
8. Brings a ticking watch near the ear form a distance.
9. Asks the patient to tell when he hears the ticking of
watch (normally heard with in a distance of two feet).
10. Tests both ears separately.
11. Compares the distance to his own ear provided his
hearing is normal (It is better to estimate the distance
on a normal individual first).
12. Talks to the patient with ordinary loud voice with
one ear closed.
13. Talks with low voice, and then talks in a whisper
if patient can hear.
14. Notes and makes comments on that examination
(If deafness is detected should, differentiate between
conduction deafness and neural deafness)
15. Performs Rinnes testexplains to the patient.
16. Uses a tuning fork of 256 or 512 Hz.
17. Holds a fork from stem in one hand.
18. Strikes the prongs on the thenar eminence of the other
hand.
19. Places the base of the fork on the mastoid process
of the patient and asks the patient whether he hears
any buzzing sound.
20. Places the prongs near his external auditory meatus
without touching the ears.
21. Asks the patient whether he can hear the buzzing
sound now or not.
22. Comments as Rinnes positive or negative.
23. Repeats the same procedure on the other ear.
24. Comments as Rinnes positive or negative.
25. Performs Webers test.
26. Uses a tuning fork of 256 or 512 Hz.

27. Holds the stem and strike the blades over the thenar
eminence of other hand.
28. Places the base of fork in the midline over the vault
of skull or midline of the forehead.
29. Asks the patient whether he can hear equally or not
in both ears.
30. Comment as whether the test is lateralized to right
or left side.
31. Helps the patient redressing (if wearing a veil)
PEARLS
a. Sometimes the hairs in front of the ear are massaged
and patient is asked to tell whether he can hear or
not.
b. Wax or any foreign body in external acoustic meatus
should be ruled out before labelling a person deaf.
c. Positive Rinnes means that air conduction is better
than bone conduction and Rinnes negative means that
bone conduction is better than air conduction.
Normally, air conduction is better than bone
conduction.
d. In nerve deafness, sound of a tuning fork is not heard
or equally less heard either through air or through bone.
e. In Webers test, in normal ears sound is heard equally
on both sides. If sound is heard better in deaf ear than
normal side, conduction deafness is present in that
ear, if it is nerve deafness in that ear, sound will be
better heard in normal ear. Tricky!
Vestibular Part of 8th Nerve (Caloric test)

The Candidate
6. Positions the patients head at 30 angle.
7. Rules out any perforation in the tympanic membrane
or any infection or obstruction in the external acoustic
meatus.
8. Asks the patient who is lying supine to focus at one
point (preferably at the ceiling).
9. Fills a syringe with 20-30 millimetres of either cold
or warm sterile water (The temperature of cold water
should be 30C and of hot water should be 44C, in
sequence).
10. Irrigates each ear with either cold or warm water for
40 seconds.
11. Notes occurrence of any nystagmus, its duration and
direction.
12. Examines both sides alternately.
PEARLS
a. The head is brought to 30 to bring the horizontal
canals in vertical plane.
b. If ear drum is perforated, hot or cold air can be
insufflated.
c. If there is canal paraesis, the duration of nystagmus
is reduced (normal is 2 minutes).
d. In coma with intact pathways, cold water causes slow
conjugate deviation of the eyes to the same side.
e. Mnemonics like COWS i.e., cold opposite, warm same
side direction of nystagmus and other is ACTH i.e.,
away from cold and towards hot are worth remembering
for quick recall.
f. Nystagmus cannot occur in a comatosed patient, as
the eyes have to be fixed. However, gaze direction can
be elicited in the comatosed patient.
Examine Glossopharyngeal and Vagus Nerves

Both these nerves are mixed nerves and share most of their
functions; therefore these two nerves are tested
simultaneously for most of their functions.
Vagus nerve is the only cranial nerve with maximum
length.
Abducent nerve is the cranial nerve with the longest
intracranial route.
The Candidate

6. Asks the patient whether he had recent meal.
7. Asks the patient to open the mouth while keeping
the tongue inside the mouth.
8. Uses a tongue depressor if necessary.
9. Looks for any pooling of saliva in the floor of mouth
and throat.
10. Notes any symmetry of the palatal arches and
pharynx.
11. Asks the patient to say Aah and observes the
movements of the palatal arches and pharynx.
12. Asks the patient to say mug, egg to note any nasal
twang in case of palatal palsy.
13. Looks for any asymmetry of fauces.
14. Touches the palate or pharynx on one side with a
cotton swab or tongue depressor.
15. Notes the gag reflex i.e., contraction of palate, pharynx
and posterior one third of tongue.
16. Examines both sides.
PEARLS
a. Sensation of taste can be examined in the posterior
1/3 of tongue in the same way as the anterior two
third of tongue but it is more cumbersome and
uncomfortable to the patient.
b. If the patient has had a meal recently, then gag reflex
should not be elicited as it can cause vomiting, therefore
it is mandatory to ask the patient about a recent meal
before such examination is carried out.
c. Position of uvula is variable at rest even in health and

should not be used as a reference point for the deviation
of the soft palate to one side.
d. Muscles move towards the normal side in unilateral
palatal and pharyngeal paralysis.
e. If hoarseness is there and vocal cords are involved,
it indicates pure vagal nerve involvement.
f. If palatal movements are normal on Ah test but no
response to tickling the soft palate occurs, this indicates
loss of sensation.
g. If ninth nerve is affected on both sides (sensory) but
10th nerve is normal no response is seen on gag reflex
but Ah test shows normal response.
h. In a patient with unilateral involvement of the 9th nerve
but a normal 10th nerve, full response is seen by
tickling normal side but no response is noted by tickling
involved side.
i. If 10th nerve is involved on one side but both 9th nerve
are normal, the posterior pharyngeal wall is pulled to
normal side when the patient is asked to say Ah and
the palatal movement is also according to Ah test.
j. If on both sides, 10th nerve is involved but the 9th
nerves are normal, contraction of muscles is absent,
so naturally tickling is more important to see whether
response can be seen; patient shows facial expression
of discomfort or the patient may stop examiner by
holding his hands and he might cough. In Ah test
the palatal movements are absent.
k. It is the response to Ah test that palatal and
pharyngeal reflexes together help to decide about the
functions of 9th and 10th nerve.
Examine Accessory Nerve

It is purely a motor nerve and supplies sternomastoid and
trapezius muscles.
The Candidate
5. Stands on the back side of the patient.
6. Inspects and compares trapezius muscles on both
sides.
7. Asks the patient to raise the shoulders and then tries
to push them down with his hands on patients
shoulders (This tests the upper 1/3 of trapezius
muscles).
8. Asks to retract scapulae against resistance and
palpates the suprascapular region for muscle
contraction (This tests the middle 1/3 of trapezius
muscles).
9. Asks the patient to face a wall and extend his arms
at elbow and with both palms placed on wall, advises
the patient to push or exert force with his both limbs.
10. Looks and feels for the fibres of lower 1/3 of trapezius
muscles.
11. Examines both sides and compares the findings.
12. Inspects the right and left side of the neck for wasting.
13. Asks the patient to turn his face towards one side
against resistance by his hand placed on the same
side of the chin and mandible.
14. Feels the opposite sternomastoid for contraction.
15. Examines both sides and compares the findings.
16. Asks the patient to bend his head forwards against

resistance offered by his hand placed under patients
chin and feels for both sterno mastoids for contraction.
PEARLS
a. Accessory nerve supplies only upper 1/3 of trapezius
whereas remaining 2/3 of trapezius is supplied by
cervical roots C3-C4 from the spinal cord.
b. Bilateral paralysis of both sternomastoid leads to falling
of the neck to the back with inability to flex the neck.
c. If you ask the patient to bend his head forwards against
resistance, then both sternomastoid muscles contract.
d. Flexion of neck will occur only on normal side whereas
on the paralyzed side, the neck will not flex.
e. Ask the patient to get up from a supine position. The
head normally leaves the pillow first.
Examine Hypoglossal Nerve

This is purely a motor nerve and supplies the muscles
of the tongue and depressor of the hyoid bone.
The Candidate
modesty.(in females wearing the veil)

6. Asks the patient to open the mouth and keep the
tongue inside (this relaxes tongue and inspection is
made lot easier).
7. Looks for any wasting, wrinkling or twitching of the
tongue.
8. Asks the patient to protrude the tongue as far as
possible in the midline.
9. Asks the patient to move the tongue side to side and
then turn upwards.
10. Asks the patient to push his cheek from inside with
the tip of his tongue and feels the resistance from
outside the respective cheek by pressing the tongue
from outside with some resistance.
11. Tests on both sides.
12. Palpates the tongue using a gauze piece while the
tongue is inside the mouth, resting on the floor of
mouth.
PEARLS
a. In unilateral hypoglossal lesions, protruded tongue
deviates to the side of the lesion.
b. Wasting of tongue appears as wrinkling and furrowing
on that side and is also called scrotal tongue.
c. Fasciculations are observed while the tongue is resting
in the floor of the mouth.
d. Normal twitching movements and fasciculations of
tongue should be differentiated from true fasciculations
which occur in motor neurone disease (MND) by the
inconsistent nature and absence of associated wasting
of tongue.
e. In facial paralysis, there might be an apparent deviation

of the tongue to one side. Compare the position of the
median raphe of the tongue in relation to the central
upper incisors.
f. When the tongue is palpated which is protruded out,
it feels apparently firm.
g. In myotonia, tapping the tongue with a sharp object
results in the appearance of a dimple.
h. If the marks of indentation of teeth occur on the lateral
side of the tongue, the tongue is presumed to be
enlarged.
i. The candidate should be aware of different types of
tongues.
j. The candidate should be able to differentiate between
upper and lower motor neuron lesions of the tongues.
Examine for Horners Syndrome

This is due to the involvement of sympathetic nervous
system affecting the cervical sympathetic ganglia and
chain.
The Candidate
modesty. (in females wearing the veil)
6. Examines the eyes for partial ptosis.
7. Looks for sunken eye (enophthalmos).
8. Looks at conjunctiva for any congestion.
9. Looks at iris and comments on any depigmentation.

10. Looks at pupil size using dull light.
11. Compares both sides.
12. Examines for light and accommodation reflex.
13. Feels for presence or absence of sweating on the face,
neck, arms and upper trunk.
14. Elicits ciliospinal reflex.
PEARLS
a. In Horners syndrome following components are
present:
Enophthalmos
Miosis
Ptosis
Anhidrosis
Loss of ciliospinal reflex.
b. The light and accommodation reflexes are normal in
Horners syndrome because pathways involved for
these reflexes are not sympathetic.
c. Adrenalin 1:1000 eye drops dilate the pupil only in
postganglionic Horners syndrome due to denervation
hypersensitivity. Cocaine dilates the pupil only in pre-
ganglionic Horners syndrome. Both these agents do
not have any effect on normal pupil.
d. Conjunctivae become congested in Horners syndrome
due to loss of vasoconstrictor activity due to sympathetic
paralysis.
e. In congenital Horners syndrome, the iris is
depigmented.
f. In bilateral Horners syndrome, only ptosis can give
a clue.
g. Absence of sweating occurs only in central Horners

syndrome, the area of anhidrosis depends upon the
level of lesion. However, in peripheral Horners
syndrome there is no anhidrosis.
h. Migraine can lead to intermittent Horners syndrome.
MOTOR SYSTEM
As already mentioned, motor system is examined under
the following headings:
Bulk of muscles
Tone of muscles
Power of muscles
Coordination
Involuntary movements
Reflexes
Gait.
The three principles of inspection, palpation and
percussion are beautifully applied in this system. Inspect
for the bulk of muscles, involuntary movements, wasting,
and palpate for the tone/pain and thickened peripheral
nerves, percuss (taping) the course of nerve to produce
tingling sensations or fasciculation, etc.
Examination of Bulk of Muscles
The Candidate
modesty.
6. Compares and looks at the muscles to have a general
idea about their size.
7. Takes a point from anterior superior iliac spine to
the middle of thigh on both sides for lower limbs.
8. Measures and compares the circumference.
9. Takes a point from the tibial tuberosity to the middle
of the calf on both sides.
10. Measures and compares the circumference.

11. Takes a point from the medial epicondyle to middle
of upper arm on both sides for upper limbs.
12. Measures the circumference and compares.
13. Takes a point from styloid process of ulna to the
middle of forearm on both sides.
14. Measures the circumference and compares.
PEARLS
a. Muscles of face, hands, feet, neck, and trunk are not
accessible for measurement. This is assessed by general
look e.g., guttering of the small muscles of hands,
prominent intercostal spaces, sunken abdomen,
prominent temporal fossae, etc.
b. For upper limbs a point from olecranon process 10 cm
above and below can be used to measure the bulk of
upper arm and forearm. Similarly, a point 18 cm above
and 10 cm below the tibial tuberosity can be used to
measure the circumference of the thigh and leg
respectively.
c. Undue prominence of the bony points can give a clue
to wasting as well.
d. Candidate should know a check list of muscle atrophy,
hypertrophy especially causes of wasting of small
muscles of hand.
Check for Tone of Muscles

It is state of tension or contraction found in healthy muscle
or resistance felt during passive movements. Tone is
assessed in the upper and lower limbs by passive
movements at the major joints.
The Candidate
modesty.
6. Asks the patient to relax the limbs e.g., lower limbs.
7. Makes the patient lie supine.
8. Places one palm under the knee joint and the other
palm over the knee joint.
9. Moves the knee joint side to side rapidly to relax the
muscles.
10. Lifts up the knee joint suddenly by placing palms
of both hands together behind the popliteal fossa.
11. Observes the behaviour at the heels.
12. Compares both sides.
PEARLS
a. Normal tone must be appreciated by candidates by
examining hundreds of patients.
b. Normal tone can not be defined in words but better
felt.
c. Another alternative method is to hold up both limbs
passively and dropping them suddenly. A hypotonic
limb drops faster than a normal one. The heels slip
down slowly if there is normal tone, rapidly if there
is hypotonia and very slowly if there is hypertonia.
d. Tone is also felt by moving the limbs at joints and feeling
for any resistances.
e. Tone is best felt during extension of the limb.

f. Spasticity is appreciated by rapid movements where
as rigidity is better appreciated by slower movements.
g. Rigidity is enhanced by asking the patient to clench
his opposite fist (Jendrassinks manoeuvre).
h. To elicit rigidity in Parkinsons disease or extra
pyramidal involvement, the movements should be
performed in small steps to feel for cog wheeling or
lead pipe rigidity.
i. Candidate should be well aware of different types of
rigidities i.e., clasp knife, cogwheel and lead pipe etc.
j. Candidate should also be aware of hypotonia,
hypertonia and their causes as a check list to be
remembered.
k. Another method to elicit tone is to place right hand
over the shin and the left hand on the middle of the
thigh and roll these hands from side to side rapidly.
In hypotonia the movement of the feet is seen as flabby
at the ankles.
Test the Power of Muscles

To test the power of muscle is to resist the action of a
muscle or a group of muscles and comment on the power,
depending on the power to be used by the examiner to
resist patients power. One should be well aware of nerve
supply and action of the muscles to be tested. Active
movements are performed by the patient whereas passive
movements are elicited by the examiner and this helps
locating the joint pain and stiffness.
The Candidate

modesty.
6. Examines the position of the limbs e.g., lower limbs
to be tested.
7. Positions the limbs properly in the opposite directions
of the movement to be tested. (For example, if
adductors of hip joints are to be tested, keep the leg
in full abduction at the hip joint and vice versa).
9. Gives a grade to the power of the muscle to be tested.
PEARLS
a. The grading should involve the followings:
i. Grade 0: No movement at all, complete paralysis.
ii. Grade 1: A flicker is present, but there is no
movement at joint.
iii. Grade 2: Patient can move limbs when gravity is
eliminated.
iv. Grade 3: Patient can move and hold against the
gravity but not against examiners resistance.
v. Grade 4: Movements are possible against gravity
and moderate resistance.
vi. Grade 5: Normal power is present.
b. It is important to note that in UMN lesions, groups
of muscles with similar joints function are affected.
Therefore, in hemiplegia, major joints are tested as
regards their movements.
c. In LMN lesions i.e., at individual level, each muscle
is tested individually.
d. Each movement during this assessment of power is

compared with examiners own strength or with his
judgment for the comparable age and built of the
patient.
e. Very simple commands should be given rather long
explanation to the patient.
f. A demonstration or gesture is more effective than any
verbal explanation.
g. Certain muscles and muscle groups are more important
than others representing particular function as a whole
or a group.
h. Certain peripheral nerves when involved require
examination of individual muscles they supply.
i. To elicit abnormal movements e.g., fasciculations, the
rubber part of patellar hammer or even the tips of three
fingers are tapped on muscle to elicit any abnormal
twitching of its fibres which is called fasciculations.
The muscles on the medial side of the thigh or calf
are used normally to elicit this response.
j. The candidate should know certain manoeuvres to
show the power of group of muscles or individual
muscle and it is obtained after repeated rehearsals and
practice.
Check Power of the Individual Muscles

In this section, a simple plan is outlined for checking power
of individual muscles and an attempt has been made to
include almost all muscles. Simple instructions are given
to the patients to check power of the muscles and these
instructions should be remembered by the candidate so
that he should not face any difficulty during examination
and this can only be achieved by continuous practice on
colleagues or actual patients. For example, measurement
of power of spinal flexion can be obtained by asking the
subject to raise his head and shoulders off the couch while
supporting his thighs. Resistance can then be added with
pressure which is applied to sternum. In checking resisted
movements, the subject is asked to prevent the examiner
from moving the part away from a fixed position. Unless
the candidate remembers these instructions to be told to
the patient and act thereafter, he would not be able to
check the power properly.
MUSCLES OF THE UPPER LIMB

Deltoid (C5, C6)
The Candidate
modesty.
6. Asks the patient to hold arm in abduction more than
30 but less than 90.
7. Presses the arm of the patient towards him.
8. Looks at the muscle contracting and feels with the
other hand the contracting middle fibres of the muscle.
9. Moves the abducted arm forwards to 60 and back
wards to 50-60 and observes and feels anterior and
posterior fibres respectively.
Supraspinatus (C4, C5, C6)

The Candidate
modesty.
6. Asks the patient to keep the arm by his side.
7. Asks him to abduct the arm against his (candidates)
resistance e.g., initial 30 of movement.
8. Palpates the muscle in the supraspinous fossa.
9. Examines both the sides.
Infraspinatus (C5, C6)

The Candidate
modesty.
6. Asks the patient to adduct arm at the shoulder and
bend the elbow at 90o.
7. Asks the patient to turn the flexed forearm backwards
against resistance which is offered in opposite
direction by him (candidate).
8. Feels for the muscle in the infraspinous fossa.

9. Examines and compares on both sides.
Subscapularis [C5,C6,(C7) ]
The Candidate
modesty.
6. Asks the patient to adduct the arms fully at the
shoulder.
7. Asks the patient to flex his elbow at 90.
8. Asks the patient to turn the forearm medially against
resistance (offered by the candidate in opposite
direction).
Rhomboids (C4 C5)
The Candidate
modesty.

6. Asks the patient to place his palm on his hip.
7. Asks the patient to push his elbows backwards
against resistance (offered by the candidate in opposite
direction).
8. Feels the muscle contracting in the infrascapular
region.
Latissimus Dorsi (C6, C7, C8)
The Candidate
modesty.
6. Asks the patient to abduct arms to > 90 at shoulder.
7. Asks the patient to adduct the arms against resistance
(offered by the candidate in opposite direction).
8. Feels for the muscle contracting in the posterior
axillary fold.
PEARLS
There are two other alternative methods to test latissimus
dorsi muscle as follows:
Method 1
Patient arm is abducted to > 90.
He is asked to cough forcibly.
Feel the muscle contracting in the posterior fold of axilla.
Method 2
Patient puts his hands behind his back.
Candidate stands behind the patient.
Candidate offers resistance to the downwards and
backwards movement of the hands.
Feels the muscle which stands out clearly.
Examines and compares both sides.
Serratus Anterior (C5, C6, C7)

The Candidate
modesty.
6. Asks the patient to stand in front of a wall and directs
him to extend his arms.
7. Asks the patient to place his palms over the wall and
directs him to push the wall with force.
8. Stands at the back of the patient and observes winging
of scapulae if the muscles are paralysed.

PEARLS
The patient will have difficulty in abducting the arm above
90 at the shoulder. The deformity becomes more apparent
as he tries to do so.
Pectoralis Major
Clavicular part (C5, C6)
The Candidate
modesty.
6. Asks the patient to raise the arms forwards.
7. Asks him to adduct against resistance (offered by the
candidate in opposite direction).
8. Observes the clavicular part which is seen contracting.
Sternocostal Part (C7, C8 and T1)

The Candidate

modesty.
6. Asks the patient to abduct the arms to about 60 and
directs him to keep elbows flexed at 90o.
7. Asks him to bring the hands together against
direction).
8. Observes the sternal part contracting.
Biceps Brachii (C5, C6)

The Candidate
modesty.
6. Asks the patient to extend the arm at the elbow joint
and directs the patient to keep the forearm in
supination.
7. Grips the wrist of the patient.
8. Asks the patient to flex his arm at elbow against
direction).
9. Observes and feels the biceps muscle contracting.

Triceps (C6, C7, C8)

The Candidate
modesty.
6. Asks the patient to flex the elbow joint.
7. Holds the patients wrist with his hand.
8. Asks the patient to extend the forearm against
direction).
9. Feels and sees the triceps muscle contracting.
10. Examines both sides and compares.
Supinator (C5, C6)

The Candidate
modesty.

6. Asks the patient to extend the elbow at the elbow
joint.
7. Asks the patient to hold his forearm in full pronation.
8. Asks the patient to supinate the forearm against
direction).
PEARLS
It is important to know that supinator muscle cannot be
either seen or felt. It is important to note that the elbow
should be extended, because if it is flexed then biceps
comes into action, which again is a supinator.
Brachioradialis (C5, C6 and C7)

The Candidate
modesty.
6. Asks the patient to flex the elbow at 90 and directs
the patient to keep the fore arm in semipronated
position.
7. Holds the wrist of the patient with his hand.
8. The patient is asked to flex his elbow further against

direction).
9. Observes for the brachioradialis muscle contracting
near the upper half of the forearm.
In checking different movements at hand, it is important
to keep hand in anatomical position i.e. the hand is placed
on a flat surface with the palm or volar surface facing
up.
Extensor Carpi Ulnaris (C7, C8)

The Candidate
modesty.
6. Asks the patient to extend his fingers and holds them
with his (candidate) hand. Patients palm facing
down.
7. Asks the patient to extend the wrist towards the ulnar
side while maintaining resistance (offered by the
candidate in the opposite direction).
Extensor Carpi Radialis Longus (C6, C7)

The Candidate
modesty.
6. Asks the patient to extend the fingers partially and
he (candidate) holds them. Patients palm facing
down.
7. Asks the patient to extend the wrist towards the redial
side while examiner exerts resistance (offered by the
Extensor Digitorum (C7, C8)

The Candidate
modesty.
6. Asks the patient to extend the fingers at metacarpo-
phalangeal joint.
7. Asks the patient to flex them at metacarpo-phalangeal
joint with force and asks the patient to keep that
extended.
8. Notes any weakness of the muscles.

Flexor Carpi Radialis (C6, C7)

The Candidate
modesty.
6. Asks the patient to place forearm with volar surface
facing up.
7. Asks the patient to flex the wrist against resistance
(offered by the candidate in opposite direction)
towards radial side.
Flexor Carpi Ulnaris (C7, C8)

The Candidate
modesty.
6. Asks the patient to place forearm with volar surface

facing up.
7. Asks the patient to flex the wrist against resistance
(offered by the candidate in opposite direction) on
the ulnar side.
8. Examines and compares on both side.
Abductor Digiti Minimi (C8,T1)

The Candidate
modesty.
6. Asks the patient to extend his elbow with the palm
facing upwards on a table.
7. Asks the patient to move his little finger away from
him.
8. The candidate applies resistance (offered by the
candidate in opposite direction) with his hand.
Flexor Digitorum Superficialis (C7,C8 and T1)

The Candidate

modesty.
6. Asks the patient to flex the fingers at proximal
interphalangeal joint (PIP).
7. Applies resistance on the middle phalanges.
8. Tests the medial four fingers.
Flexor Digitorum Profundus (C8 and T1)

The Candidate
modesty.
6. Asks the patient to flex distal interphalangeal (DIP)
joints.
7. Fixes the middle and proximal phalanges in
extension.
candidate in opposite direction) on the distal
phalanges.
9. Tests the medial four fingers.
First Palmar and Dorsal Interossei (C8 and T1)

The Candidate
modesty.
6. Asks the patient to keep the hands flat on the table.
7. Asks the patient to adduct his fore-finger against
direction) (palmar interossei).
8. Asks the patient to abduct his forefinger against
direction) (dorsal interossei).
Lumbricals (C8 and T1)

First and second lumbricals by median nerve, third and
fourth by deep branch of ulnar nerve.
The Candidate
modesty.
6. Asks the patient to extend his fingers at MP joints
and flexed at IP joints.
7. Asks the patient to extend the proximal or the distal

IP joint against resistance (offered by the candidate
in opposite direction).
8. Examines the medial four fingers.
9. Examines and compares the findings on both sides.
Abductor Pollicis Longus (C7,C8)

The Candidate
modesty.
6. Asks the patient to place the back of his hand flat
on the table.
7. Asks the patient to point his thumb towards the
ceiling.
8. Tries to resist this movement with his (candidate)
index finger.
Abductor Pollicis Brevis (C8,T1)

The Candidate

modesty.
6. Asks the patient to place back of his hand flat on
a table.
7. Places on object e.g., a pencil or a piece of a paper
between the thumb and the base of the first finger.
8. Asks the patient to keep that pencil or piece of paper
over there while exerting force against resistance
(offered by the candidate in opposite direction).
9. Examines and compares both sides for any
abnormalities.
PEARLS
a. This muscle comes into action only in the terminal part
of the abduction of the thumb. Initial part of the
movement is performed by abductor pollicis longus.
b. It is the first muscle to show weakness in carpal tunnel
syndrome.
Opponens Pollicis (C8 and T1)

The Candidate
modesty.
6. Directs the patient to keep his hand flat on a table

in such a way that the plane of thumb should remain
parallel to the plane to the palm.
7. Asks the patient to touch the pulp of the other fingers
of the same hand with the tip of the thumb.
8. The candidate tries to dislodge the contact by
introducing his index finger by making a hook.
Adductor Pollicis (C8 and T1)

The Candidate
6. Asks the patient to hold a paper between the thumb
and the palmer aspect of the forefinger.
7. The candidate tries to pull the paper while the patient
tries to hold it.
8. Examines and compares on both sides for any
abnormalities.
Extensor Pollicis Longus (C7,C8)

The Candidate

modesty.
6. Asks the patient to extend the distal phalanx of the
thumb against resistance (offered by the candidate
in opposite direction).
7. Examines and compares on both sides for any
abnormalities.
Extensor Pollicis Brevis (C7,C8)

The Candidate
modesty.
6. Asks the patient to extend the proximal phalanx of
the thumb (at the MP joints) against resistance.
Flexor Pollicis Longus (C8 and T1)

The Candidate

modesty.
6. Asks the patient to flex the distal phalanx of the thumb
against resistance (offered by the candidate in opposite
direction).
Interossei (C8, T1) (Dorsal)

The Candidate
modesty.
6. Asks the patient to abduct the fingers away from
midline.
7. The candidate offers resistance (offered by the
Interossei (C8 T1) (Palmar)

The Candidate

modesty.
6. Asks the patient to adduct the abducted fingers
(extended at DIP/PIP joints) towards midline.
PEARLS
Paralysis of lumbricals and interossei muscles can lead
to claw hand.
Trunk Muscles (Abdominal muscles) (T7 to T12 and L1)
The Candidate
modesty.
7. Asks him to place his both arms across his chest.
8. Asks him to get up without support.
9. Notes any weakness of the abdominal muscles
looking at the umbilicus and its movement.

PEARLS
a. Umbilicus is displaced towards the healthy (non-
paralysed muscle)
b. In paralysis of lower abdominal muscles the umbilicus
is pulled upwards and in paralysis of upper abdominal
muscles the umbilicus is displaced downwards. This
is called Beevors sign.
Trunk Muscles (Erector spinae)

Nerve supply: Dorsal rami of cervical, thoracic and upper
lumbar nerves.
The Candidate
6. Asks the patient to lie down in the prone position.
7. Asks the patient to clasp his both hands over his
back.
8. Asks him to raise the head over his shoulders off the
bed by extending his neck.
9. Observes for the erector spinae muscles which stands
out prominently.
Iliopsoas (Iliacus-L2, L3), (Psoas-L1, L2, L3)

The Candidate
6. Asks the patient to lie supine with both hips extended.
7. Asks the patient to flex the thighs against resistance.
PEARLS
This muscle is a flexor of the hip but as it is intra-
abdominal, therefore it cannot be seen or felt.
Diaphragm (C3, C4, C5)

The Candidate
modesty.
6. Asks the patient to take a deep breath.
7. Observes closely the movements of abdominal wall.
PEARLS
In paraesis of one side of diaphragm the abdominal wall
movements with respiration over that side are less,
compared to normal side. Abdominal wall recession is
noted instead of expansion over the concerned
hypochondrium.
MUSCLES OF LOWER LIMBS
Sartorius (L2, L3)

The Candidate
modesty.
7. Abducts the thigh partially and rotates laterally.
8. Asks the patient to flex the knee against resistance
offered by him in opposite direction.
Adductors of the Hips (L5 and S1)

The Candidate

modesty.
6. Places patients extended lower limb in abducted
position.
7. Asks the patient to bring it towards midline or bring
it inwards against resistance.
8. Notes any weakness.
Abductors of the Hips (L2, L3, L4)

The Candidate
6. Places the patients lower limb in adducted position.
7. Asks the patient to bring it out against resistance.
8. Notes any weakness.
Extensors of the Thigh (L5, S1, S2)

The Candidate
modesty.
7. Asks the patient to raise the extended limbs off the
bed.
8. Applies force upwards from below and the patient
is asked to push it down.
10. Notes any inability on the part of the patient to do
so.
PEARLS
Another method is that the patient lies supine with his
knees flexed and is then asked to extend his knees against
resistance.
Flexors of the Thigh (L1, L2, L3)

The Candidate

6. Asks the patient to lie in supine position.
7. Instructs the patient to keep his lower limbs in
extended position.
8. Asks the patient to raise the thigh off the bed.
9. Applies resistance downwards and asks the patient
to push his limb in upward direction.
10. Notes any decrease in the power of the muscles.
Rotators of the Thigh (Medial and Lateral L5, S1, S2)

The Candidate
modesty.
6. Makes the patient lie in supine position.
7. Positions the lower limbs in extended position.
8. Asks the patient to roll his limbs inwards and
outwards against resistance which the candidate
applies in opposite direction.
9. Notes down any weakness in the muscles.
Extensors of the Knee (L2, L3, L4)

The Candidate
modesty.
7. Positions his hips and knees in semi-flexed position.
8. Asks the patient to extend the knee while he
(candidate) exerts resistance by grabbing the lower
part of the leg.
9. Notes any weakness in the muscles.
10. Examines and compares on both sides
Flexors of the Knee (L5, S1, S2)

The Candidate
modesty.
6. Makes the patient lie in a supine position with his
hips and knees in a semi flexed-position.
7. Asks the patient to flex the knee.
8. Grabs lower leg of the patient and exerts resistance

in opposite direction.
Dorsiflexors of the Ankle [(L4, L5 and S1) (Dorsiflexion)]

The Candidate
modesty.
6. Makes the patient lie in a supine position.
7. Positions the legs in extension.
8. Asks the patient to pull his foot up at ankle.
9. Applies resistance in opposite direction by placing
his hand over the forefoot.
10. Notes any weakness in that group of muscles.
Plantar Flexors of the Ankle [(L4, L5 and S1, S2,

S3) (Plantar flexion)]

modesty.
7. Extends the leg of the patient at his knee joint.
8. Asks the patient to push down the foot at ankle.
9. Applies resistance in the opposite direction by placing
his palm under the fore foot of the patient.
10. Performs the same examination on the other side.
Eversion (L5 and S1, S2) Inversion (L4, L5 and S1)

The Candidate
7. Asks the patient to keep the foot in planter flexed
position and keep it above the bed not touching the
bed sheet.
8. Directs the patient to turn the foot inwards (inversion)
and outwards (eversion).
9. Exerts resistance in opposite direction of these
movements.

PEARLS
Eversion and inversion are movements that occur at the
sub-talar joints. For these movements, the heel should not
touch the ground. Similar movements which are attempted
while the heel is touching the ground are actually
abduction and adduction occurring at the mid tarsal joint.
Small Intrinsic Muscles (S1, S2)

They are very difficult to evaluate.
The Candidate
7. Asks the patient to fan out his digits.
8. Checks for abduction and adduction of the digits by
exerting pressure in opposite direction.
PEARLS
If the small muscles of the foot are involved, the foot results
in Claw foot deformity.
Extensor Hallucis Longus (L5 and S1)

The Candidate
7. Asks the patient to dorsiflex the great toe.
8. Exerts resistance in opposite direction.
Extensor Digitorum Longus (L5 and S1)

The Candidate
modesty.
7. Asks the patient to dorsiflex the toes other than great
toe.
8. Exerts resistance in opposite direction.

COORDINATION OF MOVEMENTS
Purposeful coordinated movements require intact sensory,
cerebellar and motor systems with efficient control by
higher centres. If there is weakness of muscles, the
coordination may be disturbed and becomes invalid.
Coordination should be tested both in the upper and
lower limbs on both sides, first with eyes open and later
with eyes closed.
Check for Coordination in the Upper Limbs

Method No. 1
The Candidate
modesty.
6. Asks the patient to sit on the edge of the bed if he
can do so or makes him lie down supine on the bed.
7. Asks the patient to outstretch his upper limb.
8. Asks him to extend his index finger and flex other
fingers of one hand.
9. Asks the patient to touch his (patients) own nose
with his (patients) outstretched index finger.
10. Notes any swaying of the finger.
Method No. 2
1. Candidate holds his index finger in front of the patient
and asks to look at it.
2. Asks the patient to point out his index finger.
3. Asks the patient to touch candidates finger.
4. The candidate keeps on changing the position of his

finger.
5. The candidate checks that the patient follows his index
finger accurately.
Method No. 3
1. Candidate holds his index finger in front of the
patient.
2. Asks the patient to touch his candidates index finger,
with his (patients) finger.
3. Asks him to touch his (patients) nose.
4. Keeps on doing this while changing position of his
candidates hand.
Check for Dysdiadochokinesia

Method No. 1
The Candidate
modesty.
6. Asks the patient to sit on the edge of the bed if he
can do so or makes him lie down supine on the bed.
7. Asks the patient to flex his elbow.

8. Directs him to rapidly supinate and pronate both
hands as if rolling a bulb.
9. Checks for any irregularity in the rhythm of the
movements.
Method No. 2
1. Asks the patient to hold his one palm in supine position
e.g., left palm.
2. Asks him to hold his right palm in a prone position.
3. Directs him to tap the palm of left hand with alternate
prone and supine positions of his right hand.
4. Notes any irregularity in the rhythm of the movements.
5. Asks the patient to perform the same manoeuvre on
the other side.
Heel Shin Test or Heel Knee Tibia Test

The Candidate
modesty.
6. Makes the patient lie down supine on the bed.
7. Instructs him first about the test.
8. Candidate holds his index finger 18 inches above the
patients foot e.g, right foot.
9. Asks the patient to touch it with his great toe by lifting

the leg.
10. Asks the patient to place his heel of the elevated foot
over the same knee and slide it down over the same
shin.
11. Directs him to touch the index finger of the examiner
again.
12. Asks the patient to place his heel down on the bed
again.
13. Performs the same manoeuvre on other side
14. Notes down any abnormality in the coordination.
PEARLS
a. It is important to check coordination only if the power
of muscles is greater than grade 3. Marked muscle
weakness makes this test invalid.
b. The procedure to be performed by patient in testing
coordination should always be explained to patient
before the test with proper instructions.
c. Both sides should be examined and compared.
d. All the tests should be done with both eyes open. In
case of sensory ataxia, the incoordination worsens
when the eyes are closed. In cerebellar ataxia, no
difference is noted.
e. When testing the lower limbs, make sure that the
patient should not fall down.
f. While doing the tests for coordination, smoothness of
movements, steadiness of the limbs is to be tested.
REFLEXES
Reflexes are described under two headings:
i. Deep reflexes (Tendon reflexes)
ii. Superficial reflexes
Lets us discuss first the methods to test for superficial
reflexes.
SUPERFICIAL REFLEXES
Abdominal Reflex (T7-T12 and L1)
The Candidate
modesty.
7. Exposes the patients abdomen adequately keeping
the modesty.
8. Asks the patient to keep abdominal muscles relaxed.
9. Uses either a key or an orange stick.
10. Strokes in all quadrants from outer to inner side
towards mid line. (at the end of expiration)
11. Notes the direction of movement of umbilicus which
indicates contraction of superficial abdominal muscle.
12. Performs the same manoeuvre in all the quadrants
of the abdomen.
13. Notes down any abnormality in the contraction of
abdominal muscles.

PEARLS
a. The stroking should be from lateral to medial side at
three levels.
Along subcostal area (upper abdominal muscles
T6, T7, T8)
At the level of the umbilicus (middle abdominal
musclesT9, T10, T11)
Along the line of inguinal ligament (lower
abdominal musclesT11, T12, L1) .
c. Abdominal reflexes are absent in the pyramidal
diseases and may be absent in old age and in people
with laxity of abdominal wall.
Cremasteric Reflex (L1 and L2)

The Candidate
6. Explains to the patient about the test.
7. Exposes the inguinal area properly.
8. Gives a linear stimulus along the medial aspect of
the upper part of the thigh.
9. Observes the elevation of the testicle on the same side.
10. Performs the same manoeuvre on the other side.
11. Notes down any abnormality in the elevation of testicles.
PEARLS
Alternatively, when the sartoruis muscle is pressed in the
lower third of the Hunters canal, the same sided testis
moves upwards.
Bulbocavernosus Reflex (S2, S3, and S4)

The Candidate
7. Exposes the perineal area properly keeping modesty.
8. Palpates the bulbous part of urethra using tips of
thumb and fingers of his right hand.
9. Pinches the skin over glans penis with his other hand.
10. Feels the contraction of the bulbocavernosus muscle.
11. Notes down any abnormality in the contraction of
the bulbocavernosus muscle.
Superficial Anal Reflexes (S2, S3 and S4)

The Candidate

6. Makes the patient lie down in the left lateral position
on the bed.
7. Exposes the anal area properly keeping modesty.
8. Strokes the skin near the anal area lightly.
9. Looks for the contraction of the superficial anal
sphincter.
10. Performs the same test on both sides of anus.
11. Notes and compares any abnormal response elicited.
Plantar Response (L5-S1)
The Candidate
6. Makes the patient lies down in supine position with
his legs relaxed.
7. Holds the distal part of the patients leg with his left
hand.
8. Tells the patient that he is going to scratch his sole.
9. Applies a linear stimulus to patients sole at the outer
side.
10. Starts with moderate pressure from the heel moving
towards little toe.
11. Stops short of the ball of the great toe.
13. Notes down as flexor or extensor response or

equivocal response.
PEARLS
a. The above mentioned procedure is called Babinskis
sign.
b. When the firm pressure is applied on the skin of the
tibia from above downwards, extensor response is
noted called Oppenheims sign.
c. When tendo-Achiles is pinched, the extensor plantar
response occurs and it is named as Gordons sign.
d. When the dorsum of the foot is stroked linearly near
the lateral border starting from below the lateral
malleolus to the little toe, extensor response occurs and
this is called Chaddiks sign.
e. When calf muscles are pinched, extensor response
occurs called Schaefers sign.
f. Brings sign is extensor response when dorsum of the
foot is pricked gently with a pin.
g. Goudas sign is extensor response when forceful
snapping of the second to fourth toes is done. All these
occur in advanced lesions of pyramidal tracts.
h. In advanced lesions of pyramidal tracts, in addition
to extensor plantar response, flexion of hips and knees
also occur called withdrawal response.
i. Extensor response is present in very young children
i.e., up to 12-18 months. It is also present during deep
sleep and coma without the presence of pyramidal
disease.
j. Reinforcement is done to distract the attention of the

patient to elicit these reflexes appropriately.
k. Decreased response may occur if the knee is kept flexed
or if the limb is cold.
l. Patient should be completely relaxed otherwise anxiety
may cause up going plantar.
m. In true extensor response, the extension of the great
toe occurs only when the scratching object reaches to
the middle or even to the foremost area of the foot.
Whereas, in the pseudoextensor response, it occurs in
the beginning of the stimulus.
n. Sharp object should not be used as it causes pain and
then withdrawal response.
o. The stimulus should be firm enough to produce enough
response.
p. The ball of the great toe is avoided as it causes flexion
of the great toe as a part of grasp reflex. This can occur
even if there is pyramidal lesion.
q. In flexor response, all the toes flex and are drawn
together whereas in extensor response extension of
great toe occurs first followed by fanning out of the
other toes.
r. Incomplete response is called equivocal i.e., either only
fanning or great toe extension.
s. In minimal plantar response the leg is laterally
rotated at the hip and flexed at knee. One should look
at the contraction of the adductor magnus. It is also
taken as a sign of pyramidal lesion.
t. The lateral aspect of the sole is used as the skin on
the rest of sole is quite thick and not as much sensitive
as the lateral margin.
DEEP REFLEXES
The response of these reflexes depends upon the way it
is performed, the position of the part to be tested and proper
instructions to the patient. Following are few tips to elicit
these reflexes appropriately:
I. It is important to brief the patient about the procedure
to be done. He should be shown the hammer and
domonstrate to him the impact of the hammer by
striking it on your own hand. This makes the patient
feel assured that it will not hurt him at all. Preferably
the old standard hammer is required which is flexible
and has a rounded rubber.
II. The hammer should be held from the other end and
the reflexes should be elicited by a swinging
movement in an arc before the tendon is struck.
III. Feel first the tendon to be struck.
IV. Limb is placed in particular position to elicit the reflex
appropriately.
V. Exposure of contracting muscle belly is important.
One should not look for the movement of the limb
but for the contraction of the muscles.
VI. Both sides should be examined and compared and
note should be made for any abnormal response.
VII. Try reinforcement method if the response in not elicited
appropriately. This can be done by either asking the
patient to clench his teeth or clench the fist of opposite
hand and for lower limb either asking to clench his
teeth or to interlock fingers of both hands and pulling
them apart when the reflex is being elicited. This
manoeuvre is called Jendrassiks manoeuvre. Reflexes
may normally be absent in 3-8% of normal people.
After eliciting reflex ask the patient not to clench his
teeth or fists any more.
VIII. Normal response is the contraction of muscles with

sudden displacement of the limb, which then rapidly
returns to its original position.
IX. To elicit some reflexes, the tendon is hit directly
whereas in others, the examiner places his finger and
then the tendon is struck on it.
X. The reflexes are graded according to the response i.e.
it can be normal, sluggish or absent or exaggerated
or very much exaggerated. This depends a lot on the
personal experience of the examiner as well.
Different grading is done as follows:
The reflex is absent
The reflex is present
The reflex is brisk
The reflex is very brisk
The clonus is present.
If the stimulated muscle is weak, the stimulus then
produces movement in the powerful antagonist muscle
(paradoxical or inverted reflex).
Other way of grading is as follows:
0. Not elicited
1. Elicited with reinforcement.
2. Normal
3. Brisk
4. Unsustained clonus
5. Sustained clonus.
General Principles
1. Patient is put at ease and asked to relax as much as
possible.
2. Make sure the atmosphere is warm.
3. Use same type of hammer.
4. Adopt a sequence of examining the reflexes in the same

manner. Follow a sequence and do not do examination
haphazardly. One should standardize the technique.
5. Reassure the patient that the hammer is soft and is
not going to hurt him.
6. Repeat the test if necessary.
7. Some clinicians prefer to check the tendon reflex while
the patient is sitting over the edge of the couch but
majority of clinicians prefer these tests while the patient
is lying on the bed.
INDIVIDUAL TENDON REFLEXES

Jaw Jerk
The Candidate
6. Asks the patient to open his mouth slightly.
7. The candidate places his left index finger below the
patient lower lip.
8. Gives a gentle tap with a patellar hammer, in an arc
in a downward direction, over his left index finger
already placed on patients lower lip.
9. Notes that there is an upward jerk of the jaw as
present, absent or exaggerated.
Biceps Jerk (C5, C6)

The Candidate
5. Exposes the part to be examined keeping in mind the
modesty.
7. Makes the patient either in lying in supine or sitting
position.
8. Keeps the patients elbow in flexed position at 90
and supports it with his left hand.
9. The candidate keeps the arm in semi-prone position.
10. Stands on the right side and grasps the flexed elbow
with left hand from the lateral side with the thumb
over the biceps tendon and strikes the thumb with
the hammer in the form of an arc.
11. Notes that there is an upward jerk of the fore arm
which flexes at elbow.
PEARLS
There may be inversion of the biceps jerk when the
elicited response is either absent, or there is only biceps
contraction or contraction of the triceps muscle or flexion
of the fingers.
Triceps Jerk (C6, C7, C8)

The Candidate
5. Exposes properly the part to be examined keeping
in mind the modesty (Exposes the arm up to deltoid).
8. Flexes the patients elbow with his forearm resting
on the front of his trunk across his chest.
9. Strikes the patellar hammer in the form of an arc
directly 2-4 cm above the tip of the olecranon process.
10. Notes that there is contraction of the triceps extending
the arm at elbow.
11. Examines and compare on both sides.
PEARLS
Triceps jerk is said to be paradoxical when instead of
extension at the elbow, flexion occurs.
Supinator Jerk (C5, C6)

The Candidate

in mind the modesty.
6. Makes the patient lie supine or sit up at the edge
of the bed.
7. The candidate flexes the patients elbow and supports
it with his left hand.
8. Places the patients fore arm in semi prone position
(to avoid contraction of brachioradialis muscle).
9. Strikes with a patellar hammer in the form of an arc
over the distal end of the radius about 2.5 cm above
the radial styloid process.
10. Notes for the supination of the elbow which follows
this manoeuvre.
11. Performs and compares on both sides.
PEARLS
The jerk is said to be inverted when there is absent
contraction of the biceps and the brachioradialis muscle
but finger flexion does occur.
Knee Jerk (L2, L3, L4)

The Candidate
in mind the modesty. (in this case quadriceps muscle
is exposed properly).
6. Makes the patient lie supine on the couch.

7. Flexes the knees of the patient at 15 and supports
with his left forearm sliding under both popliteal
fossae.
8. Feels for the patellar tendon.
9. Strikes the tendon with the patellar hammer moving
in the form of an arc.
10. Observes and notes the contraction of the quadriceps
muscle on both sides.
Method No. 2
The Candidate
1. Lifts up the right knee with the palm of left hand, by
placing it under the right popliteal fossa.
2. Feels the tendon of the patella.
3. Strikes with the hammer.
4. Notes contraction of the quadriceps femoris muscle.
5. Straightens the right knee, lifts up the left knee with
left hand by doing the same manoeuvre.
6. Strikes the patellar tendon with hammer.
7. Comments and notes contraction of quadriceps muscle.
Method No. 3
The Candidate
1. Pushes the dorsum of his left forearm under the right
knee.
2. Rests the palm of left hand over the front of left knee.
(The right knee becomes flexed).
3. Strikes the patellar tendon of the right knee with the
patellar hammer.
4. Takes out the left arm and now puts the dorsum of
his left forearm over the right knee.
5. Places the palm of his left hand under the left knee.
6. Bends the left knee.
7. Strikes the patellar tendon of the left knee with the
hammer.
8. Notes and comments on the findings.
Method No. 4
The Candidate
1. Makes the patient sit at the edge of the bed.
2. Asks the patient to hang down his legs freely.
3. The candidate stands by the side of patient with his
back facing as the patients back.
4. Strikes the patellar tendon with the hammer on each
side.
5. Notes the contraction of the quadriceps femoris muscle.
Ankle Jerk (S1, S2)

The Candidate
in mind the modesty in this case calf muscles are
exposed properly.
7. Instructs the patient to place the lower limb in
abduction and externally rotated position at the hip
and slightly flexed at the knee.
8. Dorsiflexes the foot at the ankle with left hand.

9. Holds the patellar hammer in his right hand.
10. Strikes the Achilles tendon with the hammer in a semi
arc movement.
11. Notes the contraction of gastrocenemius muscle.
12. Performs the same manoeuvre on the other side and
compares it.
Method No. 2
The Candidate
1. Flexes the patients right limb at the knee.
2. Places the shin part of the limb on the shin of opposite
limb.
3. Dorsiflexes the foot slightly with his left hand.
4. Strikes the Achilles tendon with the patellar hammer
in a semi-arc movement.
5. Same manoeuvre is repeated on the opposite side.
PEARLS
By doing this method, the other foot does not come in the
way of patellar hammer during striking.
Method No.3
The Candidate
1. Asks the patient to kneel over the seat of a chair with
his/her feet hanging out the edge of the seat.
2. Exposes the lower legs adequately keeping in mind
the modesty.
3. Asks the patient to relax.

4. Strikes the tendo-Achilles alternatively to see the
response.
6. Notes any delayed relaxation of the ankle jerk (better
noted in cases of hypothyroidism).
Method No. 4
The Candidate
1. Keeps the patients lower limb in extension at knee.
2. Faces towards the feet of the patient.
3. Places his left hand over the fore foot of the patient
and dorsiflexes passively the fore foot.
4. Strikes with patellar hammer on his fingers of the left
hand already placed on patients fore foot.
5. Notes and feels that the foot is plantar flexed due to
contraction of calf muscles.
MISCELLANEOUS REFLEXES
Check for Finger Flexion Jerk
The Candidate
5. Asks the patient to keep his hand flat on the table
with the palm facing the ceiling.
6. Places tips of his middle and index fingers across
the palmar aspect of the proximal phalanges of the
patients relaxed fingers.
7. Taps lightly on his own fingers with the hammer.
8. Notes flexion (whether slight or brisk) of the patients

fingers.
compares it.
PEARLS
This jerk is brisk in pyramidal tract lesion.
Check for Hoffmans Sign

The Candidate
5. Asks the patient to keep his hand relaxed.
6. Holds the middle finger of the patient by the sides
at the distal interphalangeal joint
7. Flexes that distal interphalangeal joint.
8. With the other hand holds the tip of the same middle
finger and flicks into extension.
9. Notes the flexion of the thumb of the same hand.
compares it.
PEARLS
In pyramidal tract lesion the thumb flexes quickly and
may be accompanied by flexion of the other fingers as
well. This is called positive Hoffmans sign.
Elicit Wartenbergs Sign

The Candidate
5. Asks the patient to keep his arm supinated with
fingers flexed.
6. The candidate keeps his arm prorated and flexes his
fingers.
7. The candidate inter locks his fingers in to patients
fingers.
8. Both pull against each others resistance.
9. Notes the extension of the thumb of the patient which
occurs normally.
compares it.
PEARLS
In pyramidal tract lesion, the thumb adducts and flexes
strongly.
GAIT
It is the mode of walk of an individual. Gait varies from
individual to individual even if they are normal. However,
few gaits are specific for a particular neurological disease.
Before the gait is assessed it is very important to ask
the patient whether he can walk at all or not. It is also
very important to note the following points during
examination:
The Candidate
1. Exposes the legs of the patient properly keeping
modesty.
2. Asks the patient to take off his shoes and socks.
3. Instructs the patient to walk away from him freely.
4. Asks the patient to turn around at a certain distance
e.g., 10 meters away from him.
5. Closely observes while the patient is coming towards
him.
6. The candidate notices the type of gait, whether normal
or abnormal and also notes presence of the swinging
of the arms.
PEARLS
a. Important points to note are the posture of the body
while walking, the position and movement of the arms,
the distance between the feet, the smoothness of the
movements of the legs, the ability to maintain a straight
course, the ease of turning and finally stopping.
b. This test becomes more reliable if the patient is asked
to do tandem walking.
c. The candidate should be aware of different types of
gaits and should be able to recognize them immediately
e.g., hemiplegic gait, festinant gait, scissor gait,

staggering gait, waddling gait, stamping gait, high
stepping gait, shuffling gait, ataxic gait etc.
Few important points worth remembering include the
following:
1. Can the patient walk at all?
2. How much help is needed?
3. Can the patient walk in a straight line or is there a
deviation to one side or the other?
4. Does the patient tend to fall?
5. If so, in which direction he tends to fall?
6. Can the patient turn quickly at 180?
7. Is there a recognizable gait disorder?
INVOLUNTARY MOVEMENTS
These movements are not under the control of the will,
therefore they occur involuntarily.
Following points should be observed:
1. Which part of the body is affected?
2. What is the pattern of the movement?
3. Is it repetitive or non repetitive?
4. Is it symmetrical or asymmetrical?
5. What is its frequency?
6. What relieves it?
7. What aggravates it?
8. Does it persist during sleep?
9. Is it acute or insidious?
10. Is it temporary or progressive?
11. What is the type of movement?
It is better to observe the patient at a distance.
The candidate should be aware of different types of
involuntary movements and hence should be able to spot
diagnosis. For more details of these involuntary
movements, the candidate should consult a Textbook of

Medicine or for detailed account of these movements, a
standard Textbook on Neurology.
These involuntary movements include tremors, pill
rolling movements, chorea, athetosis, choreoathetoid
movements, myoclonus, hemiballismus, dystonia,
myokymia, diskinesia, blepharospasm, ticks, hemifacial
spasms, torticolis, fasciculations, convulsions, tetany, etc.
CLONUS
When sustained stretch is maintained on a tendon of a
muscle, then rhythmic contraction and relaxation of the
concerned muscle occurs. This is called clonus. It is usually
a sign of pyramidal tracts lesion. If these movements are
not sustained, it is called pseudoclonus.
Patellar Clonus
The Candidate
5. Exposes properly the lower limb up to the mid thigh
position keeping in mind the modesty.
6. Makes the patient lie supine on the couch with the
knee fully extended.
7. Holds the lateral parts of patella with the thumb and
index finger of the left hand.
8. Pushes it down towards patients feet with a sudden
jerk.
9. Maintains some pressure in the same position.
10. Notices sustained up and down movements of patella
which are elicited.
11. Notes and comments on the findings after examining

both sides.
Ankle Clonus
The Candidate
5. Exposes properly the lower limb up to the mid thigh
keeping in mind the modesty.
7. Flexes the knee partially and supports it form the
popliteal fossa with left hand.
8. Everts the foot slightly with the right hand and
suddenly dorsiflexes the distal part of foot with the
same hand in the form of a jerk.
9. Maintains stretch in the same position for few
seconds.
10. Notes sustained rhythmical movements of dorsi-
flexion and plantar flexion of the foot.
Wrist Clonus
The Candidate

5. Exposes properly the upper limb up to the elbow
keeping in mind the modesty.
6. Holds the forearm of the patient with his left hand.
7. Extends the wrist passively with some force.
8. Maintains the stretch for a while.
9. Feels the rhythmic movements of extension and
flexion at wrist.
10. Examines both sides.
11. Comments on clonus present or absent.
PEARLS
If the number of contractions is less than six, then it is
called ill sustained and if they are more than six it is well
sustained clonus.
True clonus is associated with extension response and
is stopped by flexion of that particular joint.
SENSORY SYSTEM
The sensory system is divided into three parts:
1. Superficial sensations.
2. Deep sensations.
3. Cortical sensations.
SUPERFICIAL SENSATIONS
These include:
a. Touch
b. Pain
c. Deep pain
d. Temperature.
Touch
The Candidate
5. Exposes properly keeping in mind the modesty.
6. Takes a wisp of cotton wool.
7. Shows it to the patient and instructs him properly.
8. Touches the patients skin lightly.
9. Asks him to close the eyes before he touches him with
a cotton wisp.
11. Tests the sensations from scalp to sole.
12. Proceeds downwards dermatome by dermatome.
13. Avoids hairy areas of the body.
14. Notes the area of abnormality.
15. Compares on the opposite side.

examiners.
PEARLS
a. The tip of wisp of cotton wool should be fine and area
should be touched with its tip because if cotton is
touched as a whole fluff; the area of stimulation is quite
large and can mislead the findings.
b. It is also advised to touch lightly once and not to scratch
over the skin.
c. The candidate should know the following terms while
checking for the sensation of touch:
Hypoaesthesia
Hyperaesthesia
Anaesthesia
Paraesthesia
Pain
The Candidate
6. Uses a sharp common pin.
7. Shows it to the patient and instructs him properly.
8. Asks him to close the eyes before he touches him with
a pin.

examiner.
Elicit Deep Pain

The Candidate
6. Informs the patient that he is going to squeeze one
of his muscles or tendons.
7. Squeezes the muscle or tendon.
8. Looks at patients face for expression of pain.
examiner.
PEARLS
a. An ordinary domestic pin is preferred over a
hypodermic needle because the hypodermic needle cuts
the skin relatively painlessly and therefore it is not
suitable for sensory testing.
b. Patient should recognize the stimulus as pain and not
as touch.
c. Single prick may not always register as pain. One
requires multiple stimuli.
d. Look at patients face because if he feels pain he will
wince.
e. The candidate should know the following terms while
checking for the pain sensation:
Analgesia
Hypoalgesia
Hyperalgesia.
Temperature
To perform this test warm and cold water should be kept
in two tests tubes. The warm water should be 37-40C
and cold water should be at a temperature of 30-32C.
The Candidate
6. Takes hot and cold test tubes which should be
identical.
8. Touches the skin of the patient with cold and warm
water haphazardly.
9. Asks the patient to say yes when he feels whether

hot or cold.
examiner.
PEARLS
a. Another crude method is to touch with a metal of clip
board or handle of patellar hammer for warm and cold
response respectively. This method is applicable when
there is no availability of the test tubes.
b. Loss of temperature is called thermoanaesthesia
c. Presence of touch sensation with loss of pain and
temperature senses is called dissociated sensory loss.
DEEP SENSATIONS
These include:
a. Sense of vibration
b. Joint sense
c. Sense of position
d. Rombergs sign.
Sense of Vibration
The Candidate

6. Uses a 128 Hz tuning fork.
7. Strokes on the ball of the thumb the prongs of the
fork.
8. Demonstrate the vibrating and non-vibrating tuning
fork to the patient.
9. Asks him to close the eyes and places vibrating fork
over medial, lateral maleoli then tibial tuberosity and
then anterior superior iliac spine while checking sense
of vibration in the lower limbs.
10. Places the stem of vibrating tuning fork at the
olecranon process then sternum and the forehead.
11. Compares on the both sides and notes any
abnormality.
14. Comments on his findings while presenting to
examiner.
PEARLS
a. Bony prominences are used as the vibration sense is
amplified on these prominences.
b. For minimal vibration loss following method is used:
Places the stem of the fork on the patient.
Asks him when the vibrations are no more felt.
Places the fork on himself to know whether the
vibration are still perceived nor not.
c. 128 Hz tuning fork is used because it has a long
decay time i.e., 15-20 seconds which is enough time
to perform this test successfully.
Sense of Joint Position

It is very important to explain to the patient about this
aspect of examination. Proper instructions to the patient
will yield better elicitation of this test.
Method No. 1
The Candidate
6. Selects the great toe for checking the sense of position
in the lower limbs.
7. Fixes proximal phalanx of big toe with fingers of the
left hand and thumb.
8. Holds the lateral sides of the big toe with his index
finger and thumb of the right hand.
9. Move it up and down first and shows it to the patient
as well and makes sure that he understands the
instructions.
11. Moves the toe up and down in small movements.
12. Asks again from the patient whether it moves up or
down or does not move at all.
14. Compares on both sides.
17. Comments on his findings while presenting to
examiner.
PEARLS
a. The joint should be moved in small movements and
it should be slow and should not be over stretched
as the patient comes to know which direction the joint
has moved. This makes the sensitivity of the test invalid.
b. A normal person can appreciate 12-15 movements.
c. One should hold the toe from side without touching
other toes to minimize the contact area which becomes
much more if the toe is held from dorsal and ventral
side.
Method No.2
The Candidate
6. Asks the patient of close his eyes.
7. Places one limb of the patient in any position.
8. Asks him to keep the opposite limb in the same
position.
9. Tests both the upper and lower limbs.
11. Compares on both sides.
14. Comments on his finding while presenting to the
examiner.
Methods No.3
The Candidate
1. Asks the patient to extend his arms outwards.
2. Instructs him to close his eyes.
3. Asks the patient to bring his two index fingers together.

4. Notes whether he can do it or not.
5. Notes down the abnormality.
PEARLS
In normal individual, error in approximating the fingers
should be less than one centimeter.
Method No. 4
The Candidate
1. Places patients arm in a particular position.
2. Moves it away.
3. Asks him to replace it in previous position.
4. Asks the patient to place the opposite limb in a similar
position.
PEARLS
a. At least six successive responses are correct, the test
is deemed to be normal.
b. If patient is not able to understand the maneuver at
all, then move his joint and ask whether the joint moved
at all or not.
c. In joint position impairment, the distal parts are first
affected; therefore the test is started from the distal part
of the limbs. If the test is positive at distal part then
there is no point to test proximally.
Rombergs Sign

6. Asks the patient to stand with both feet close together.
7. Observes whether he is steady in posture or not (with
eyes open)
8. Asks him to close his both eyes.
9. Observes any change of steadiness or posture.
PEARLS
If unsteadiness occurs on closing the eyes, it is positive
Rombergs sign. It indicates defect in the sense of position
and is called sensory ataxia.
In case of cerebellar or vestibular diseases, unsteadiness
is present even with the eyes open and it does not increase
significantly if the eyes are closed.
CORTICAL SENSATIONS
These inclue the followings:
i. Tactile localization
ii. Tactile discrimination
iii. Graphaesthesia
iv. Stereognosis
v. Sensory inattention.
Tactile Localization
The Candidate

7. Touches the patients skin with wisp of a cotton wool.
8. Asks the patient to localize with his finger tip where
the cotton was touched.
9. Asks the patient to tell the site of touch if the patient
is paralyzed.
10. Tests on both sides, from head to toe and different
parts of the body.
examiner.
PEARLS
The touch localization is more precise at the periphery
of the limb than at the proximal parts.
Tactile Discrimination
The Candidate
6. Takes a divider or two pins in each hand.
7. Shows it to the patient and explains the test to him
before actually doing it.
9. Stimulates the skin simultaneously at two points
making sure that and intensity of both stimuli should
be the same.
10. Starts with the dividers prongs as apart as possible

and then brings them together gradually.
11. Notes whether the patient is able to recognize the
stimulus as one or as two different stimuli or none
at all.
12. Examines fingers, palms, feet and the back.
13. Examines both sides and compares the same areas.
Or
The Candidate
1. Brings the two stimuli close together until the patient
recognizes them as one.
2. Examines fingers, palms, feet and the back.
3. Examines both sides and compares the same areas.
4. Notes the findings and compares on both sides.
PEARLS
a. Do not use sharp objects as it causes discomfort and
pain to the patient.
b. Normal two point discrimination is:
2-5 mm on the finger pulps.
1-2 cm over the palms.
2-3 cm over the soles.
3-5 cm over the trunk.
c. Patients eyes should be closed during this test.
Stereognosis
Before doing this, make sure that the sensations are present
in the palm. Make sure that the small joints of hands and
the muscles are normal too as the patient has to feel for
the objects given to him with eyes closed and he has to

make certain movements of the hand to recognize it.
The Candidate
7. Places common objects in patients palms i.e., coin,
keys, pen, wallet etc.
8. Asks him to recognize them with his eyes closed.
9. Waits for the patient to recognize things only by
touch.
10. Compares the speed and accuracy on both sides.
PEARLS
Loss of ability to identify objects is called astereognosis.
Graphaesthesia
The Candidate
6. Explains the test to the patient.
7. Uses a blunt object.

8. Holds the patients palm in his hand.
9. Asks him to close the eyes.
10. Draws legible numbers or letters on the patients palm
with that blunt object (Skin of the forearm can also
be used).
11. Starts with easy numbers i.e., 1, 2, 7, then with difficult
one 0, 6, 8, and then double numbers.
12. Compares the findings on both sides.
PEARLS
Before performing this test it is important to know the
education level of the patient.
Sensory Inattention
The Candidate
6. Explains the test to the patient.
7. The candidate holds two blunt objects i.e, pin heads
in his hand.
8. Stimulates the skin with this on one side as well as
on the opposite sides of the body simultaneously.
9. Asks the patient to indicate which side or sides are
touched.

PEARLS
a. In sensory inattention, while on stimulating both sides,
one side is not perceived.
b. Similar principles can be used to test for visual
inattention and auditory inattention.
GENERAL PRINCIPLES FOR EXAMINING

SENSORY SYSTEM
Following important points should be followed while
examining the sensory system:
1. Explain the procedure to the patient in full detail.
2. Make sure that he understands all the instructions
given to him.
3. Both the patient and the examiner should have patience
in performing the examination of this system.
4. Patients eyes are covered properly during examination.
5. Move the stimulus from impaired area of sensation to
normal area for early localization of the abnormal
sensory area.
6. Uniform stimuli should be produced while testing
sensations.
7. Both sides of the body should be checked and compared.
8. Mark out the area of sensory disturbances and look
whether they correspond to specific nerve distribution.
9. The spinal segments are not necessarily at the level
of corresponding vertebrae. They correspond to
vertebral level only in higher cervical region.
10. To determine which spinal segment is related to a given
vertebral body following scheme is used:
For cervical vertebrae add 1 level
For thoracic vertebrae 16 add 2 levels
For thoracic vertebrae 79 add 3 levels

10th thoracic arch lies over L1 and L2 segments
11th thoracic arch lies over L3 and L4 segments
12th thoracic arch lies over L5 segment
First lumbar arch lies at sacral and coccygeal
segments
In the lower thoracic region, the tip of the spinous
process makes the level of the body of vertebrae
below.
CEREBELLAR SYSTEM
Cerebellum is an important part of the nervous system
as it completes the circuit by processing information about
the state of motor activity and modifying cortical activity.
It is important part in coordination, relaxation of agonist
and antagonist muscles. Its diseases can lead to presence
of involuntary movements. It also plays an important role
in maintaining the position of different parts of the body
at will.
Most of the signs of cerebellar diseases occur due to
two cardinal features i.e., hypotonia and in-coordination.
Start examining as follows:
The Candidate
6. Notes any involuntary movements or altered posture.
7. Looks for spontaneous nystagmus.
8. Elicits it if not present (See on page 194).
9. Talks to the patient and notes any change in the
character of speech (See on page 177).
10. Checks for hypotonia.
11. Tests for coordination and performs finger to finger
or finger to nose test and heel shin test.
12. Performs dysdiadochokinesia.
13. Performs rebound phenomenon as follows:
i. Asks the patient to hold his arm semi-flexed at elbow.
ii. Holds his arm and asks him to flex against power
exerted by examiner.
iii. The candidate takes off his hands from the patient.
iv. Notes whether flexion movement is quickly arrested
or not.
14. (In positive test, the patient hits his face or side with
his limb as he has no control over his movements)
15. Performs the knee jerk, and notes that it is pendular.
16. Checks gait and notes its type by asking the patient
to walk on straight line.
SIGNS OF MENINGEAL IRRITATION

These signs are elicited to help diagnosing meningitis.
The Candidate
6. Makes the patient lie down flat in supine position.
7. Keeps the patients lower limbs in extended position.
8. Places his palm of left hand under the occiput of the
patient.
9. Keeps the right palm over the front of chest to stabilize
the upper trunk.
10. Tries to flex the neck of the patient passively.
11. The candidate feels for the stiffness in the neck of
the patient.
12. Flexes the hip at 90 and the knee at 90o.
13. Extends the patients knee passively.
14. Notes that the patient complains of pain and restricts
him to further examine him.
15. Flexes the neck passively.
16. Notes flexion of both the knees.
17. Flexes one leg passively.
18. Notes that other limb is also flexed.
PEARLS
a. Normally one can touch ones chin without any
discomfort.
b. Normally the knee can be extended up to 135 without
producing pain.
c. The steps number 8-11 indicate neck stiffness.
d. The steps number 12-14 indicate Kernigs sign.
e. The steps number 15-16 indicate Brudzinskis neck
sign and steps numbers 17-18 indicate Brudzinskis
leg sign.
f. Absent neck rigidity but positive Kernigs sign indicates
meningeal irritation at the level where spinal nerve
roots supplying the hamstring muscle emerge out.
PRIMITIVE REFLEXES
These are present in normal newborn infants and as they
grow older, these reflexes disappear varying up to the age
of 4 months to 18 months. The absence in new born may
indicate some abnormality and ironically, their presence
in the adults indicate abnormality in the neurological
system.
These reflexes are as follows:
Palmomental Reflex
The Candidate
6. Asks the patient to place his hand over a flat surface
with the palm facing upward.
7. Scratches the skin near the thenar eminence.
8. Notes a brief puckering at the chin.
9. Examines both sides and notes any abnormality.
12. Comments on his findings white presenting to
examiners.
PEARLS
One can do this on the soles but that is not as strong
as palmar response
Grasp Reflex
The Candidate
7. Strokes gently the radial aspect of the palmar surface
of patients hand.
8. Begins proximally and proceeds distally between the
patients thumb and index finger up to the finger tips.
9. Notes that the patient flexes the thumb and fingers
to grasp the stimulus.
10. Notes that the grip increases with increasing traction.
examiners.
Avoidance Reflex
The Candidate
7. Strokes the ulnar aspect of the patients hand.

8. Notes that it moves away from the stimulus.
examiners.
PEARLS
This reflex is elicited if grasp reflex is present.
Snout Reflex
The Candidate
6. Presses or taps gently the patients lip when mouth
is closed.
7. Notes the puckering or pouting of the lips and
contraction of the facial muscles on the same side.
Suckling Reflex
The Candidate

6. Asks the patient to close his mouth.
7. Strokes the angle of the mouth which is already closed
(tactile). (Or brings his index finger near the angle
of the mouth, while the patient is looking at it (visual).
8. Notes that anticipatory opening of the patients mouth
occurs.
Glabellar Tap
The Candidate
6. Asks the patient to keep his eyes open and look ahead.
7. The candidate stands behind the patient.
8. Brings the middle finger or index finger from above
and strikes gently at the place between the two
eyebrows (glabella).
9. Notes that the patient blinks his eyes with each tap.
PEARLS
a. In normal subjects, 3-4 blinks occur initially and then
blinking stops even if one continues to tap at the
glabella.
b. The finger should be brought from behind because if
it is brought from front, it directly stimulates blinking
therefore the test becomes invalid.
c. Glabellar tap is usually positive in patients who have
Parkinsons disease or extrapyramidal tract lesions.
d. Sometimes the eyelids continue to blink even if the
stimulus is no more there which strongly supports the
diagnosis of Parkinsons disease or conditions
involving extrapyramidal system and in dementia.
e. Again to mention that all the above reflexes are
normally present in the new born and disappear
around 4-6 months of age in normal babies. They are
always pathological in adults.
f. The avoidance reflex is released in the contra lateral
parietal lobe lesion.
g. The palmomental and grasp reflexes are released on
the same side in case of contralateral frontal lobe
disease.
h. If all these reflexes are released on both sides, they do
not carry any significance.
CHECK FOR BRAINSTEM DEATH OR BRAIN DEATH

The brain is an important part of the body and controls
all functions appropriately and in order. The brain stem
which is formed of mid brain, pons and medulla along
with upper part of spinal cord is more important as it
carries all the tracts in a condensed form and also has
cardiorespiratory centers, which control circulation and
respiration. Therefore any damage to brain stem can prove
fatal.
If a patient is in deep coma, then the out come is not
very good as the patient is in a vegetative state. The patient
may be on ventilatory support and inotropic support to
keep going the cardiorespiratory functions. However, this
cannot be pulled on for a long time and one has to perform
certain tests on daily basis to know or confirm Brain Death.
These tests are as follows:
The Candidate
1. Shines the light into patients eyes and sees the size
of the pupils and their response to the light.
2. Checks for the corneal reflex with a wisp of cotton
wool.
3. Performs cilospinal reflex to see the response (see
under Horners syndrome).
4. Presses the skin with underlying bony structure and
sees the response to this painful stimulus.
5. Checks for the gag reflex and notes whether present
or absent.
6. Checks for spontaneous respiratory effort by placing
a thin paper in front of the patients nostril or his
hand.
7. Checks caloric test and interprets it.
8. Checks for dolls eye phenomenon as follows:

Grasps the head of the patient with both hands
from the temples.
Uses thumbs to gently hold the upper eyelids and
try to open it.
Rapidly rotates the patients head side ways to
about 90.
Notes the movements of the eye balls.
Flexes and extends the neck alternately.
Notes the movements of the eye balls.
PEARLS
a. When the brain stem is intact the patients eyes deviate
to opposite side of the head while moving the neck.
However in case of brain stem death, the eyes are fixed
and move in the same direction of the head. In the
former it is called dolls eye present and the later dolls
eye absent. It is the dolls eye absent which confirms
brain stem death.
b. When the assessment of brain death is made, the CO2
and O2 level must be with in normal range.
CHECK ELICIT PAIN IN THE PATIENT

For this purpose, the examiner should be well aware of
the points where more pain can be elicited. Such objective
can be achieved by pressing or pinching with your
knuckles or fingers respectively.
The Candidate

6. Pinches the trapezius muscle with his index finger
and thumb and notes the response of the patient.
7. Presses the manubrium sternii with his knuckles of
the fist and notes the response of the patient.
8. Presses the patients nail at the nail bed with some
hard object i.e., pen or chest piece of the stethoscope
and notes the response of the patient.
9. Places a pencil or a pen between the two fingers and
squeezes them and notes the response of the patient.
10. Pinches the adductor longus muscle just above the
knee on the medial side and notes the response of
the patient.
11. Squeezes the tendo-Achilles and notes the response
of the patient.
PEARLS
The supra orbital ridge is not used as the site for eliciting
pain (by pressing at the supra orbital notch) because the
thumb can slip over the supraorbital ridge and can cause
damage to the eye. One should avoid this.
ELICIT FOCAL NEUROLOGICAL SIGNS IN AN

UNCONSCIOUS PATIENT
This examination requires a good basic knowledge of
anatomy and neurological examination techniques. Still
it is impossible to identify all the signs; however few
detectable signs help to localize the lesion.
The candidate should follow important points listed below:
1. In cerebral lesion the neck is rotated to the side of lesions
along with eyes which are deviated to the same side.
2. In third nerve paralysis, the pupil on the affected side
is dilated and does not react to light. The eye ball is
deviated in outwards and downwards direction.
3. In 7th nerve paralysis, there is loss of nasolabial fold
on the same side. The angle of the mouth is deviated
towards healthy side. The mouth puffs during
expiration on the affected side. There may be drooling
of saliva from that side as well.
4. To see the side of paralysis, raise the upper limb and
allow falling freely. If it is paralyzed, it will fall
suddenly and will adopt any posture; even it can hurt
the patient by falling on him. Non paralyzed limb falls
slowly as compared to the paralyzed limb.
5. To see which limb is paralyzed e.g., lower limbs, while
the patient is lying supine in the bed, note the position
of the limbs. If it is paralyzed, the lower limb is rotated
laterally as compared to nonparalyzed limb. If one
allows it to fall freely, same scenario will be seen as
in the upper limbs.
HOW TO CONFIRM THAT PATIENT IS

PRETENDING PARALYSIS?
For Upper Limbs
The Candidate
7. Lifts up one of his arms (claimed to be paralyzed)
with his (candidate) arm.
8. Throws that arm over patients face or chest.
9. Observes and notes which way the limb lands.
12. Comments on findings while presenting to the
examiner.
PEARLS
In paralysis (true) the limb will fall freely any where over
the patient even hurting him, where as in pretended
condition, the limb does not fall freely and usually away
from the face or chest to avoid injury.
Other Method
The Candidate
1. Asks the patient to press down his (candidates) hands
with both of his (patients) hands.
2. Feels the pressure under the so called paralyzed hand,
as the patient un intentionally grips down that hand
as well. If it was paralyzed, then there would be no

pressure felt.
For Lower Limbs

The Candidate
6. Makes the patient lie down supine.
7. Puts his one hand over the lower part of patients
non-paralysed shin.
8. Puts the other hand under the lower part of the
patients paralysed shin on the other side.
9. Asks the patient to lift the normal leg upwards.
10. Feels the pressure over the other hand under the
paralysed side.
PEARLS
If one side is truly paralyzed, one will not feel any pressure
and if the side is not paralyzed, one will feel downwards
pressure on the paralyzed side when the normal leg
is lifted up.
CHAPTER 11
Dermatological
Examination
This system is discussed under four headings as follows:-

1. Principles of examination.
2. Dermatological examination as a whole.
3. Schematic out line of dermatological examination.
4. Common commands.
PRINCIPLES OF DERMATOLOGICAL
EXAMINATION
Before examination, one should know that skin is the
largest organ of the body. It comprises sixteen percent of
total body weight. It functions as a sensory organ, organ
of metabolism that has synthesizing, excretory and
absorptive function, a protective barrier against the external
environment and an important factor in temperature
regulation. One should also know that skin is synergistic
with internal organ systems; therefore it reflects pathologic
processes that are either primary else where or shared in
common with other tissues. The diseases initially
characterized as solely cutaneous e.g., SLE, have often
subsequently been found to involve several systems.
The examination should be done in well-lighted room with
natural light if possible or a daylight type of lamp. The
patient should be exposed properly. When feasible the
patient should be gowned and examined completely
systematically in sections, quadrants or from head to toe.
The examination should commence with a general
assessment of the patient as a whole. The survey should
include an appreciation of the colour, degree of moisture;
turgor and texture of the skin colour, design of the material
of which the clothing of the patient is made of should
also be noted.
DERMATOLOGICAL EXAMINATION 315
In the examination of the skin, one should examine

the morphology of individual lesions, their overall pattern,
spatial relationship to each over and their distribution.
Specific attention to hair, nails and the mucous membranes
is required. In addition to naked eye examination in natural
light, one should use special techniques while examining
the skin lesion e.g., magnification with hand lens, subdued
lighting in the examining room, oblique lightening of the
skin lesion in a darkened room, woods lamp examination
or diascopy of the skin lesion.
Palpation of rashes or localized lesions imparts additional
information about texture, consistency, thickness,
tenderness and temperature. Gentle scratching or rubbing
alters visibility of scaling or may elicit dermo-graphism.
The main touch modalities in examining the skin include.
Simple palpation, blunt pressure, linear or shearing
pressure, squeezing, pinching, scratching, scrapping
scorching with or without picking off the scales of skin
lesions, diascopy, dermoscopy or iodine-starch test.
Additional simple clinical examination includes. Wetting
of the skin lesion, application of heat or cold to skin, pin
prick examination or pressing of the skin lesion. Gloves
should be worn for examination of the mouth, genitals
or perianal region or while examining an infective lesion.
STEP BY STEP FOR EXAMINATION OF THE SKIN

(FOR LONG CASES)
The Candidate
permission of examination.
3. Exposes the patient properly and makes sure the light

is natural and adequate.
4. Does a general survey of the patient as a whole. Notes
the colour and degree of moisture of the skin.
5. Notes colour, design and material of which the
clothing of the patient is made of.
6. Establishes the morphology of the lesion: macule,
papule, nodule, tumor, wheal, vesicle, bulla, pustule,
crust, scale, erosion, ulcer, fissure, atrophy, scar,
poikiloderma, pachyderma or lichenification.
7. Notes the size of the lesion; pin point, pin head, millet
seed, lentiform, coin or plaque.
8. Notes the shape of the lesion; discoid, petaloid,
arcuate, annular, polycystic, livedoreticularis, target
lesions, stellate, rosettes, digitate, linear, serpiginous
or whorled.
9. Notes the margins/borders of the lesions; diffuse,
well-defined, regular, irregular, rolled, undermined
or punched out.
10. Notes the colour of the skin and of lesion; white-ivory,
black, blue, blue-grey, brown, red, scarlet-red, yellow,
orange, purple, voilaceous or green.
11. Notes the pattern of the lesions; aggregate, grouped,
satellite, confluent, scattered, disseminated, spared,
linear, zosteriform.
12. Assesses the distribution of lesions; unilateral,
bilateral, symmetrical, asymmetrical, localized,
generalized, follows lines of Blaschko, nervous or
vascular supply, limited to distribution of skin
appendages or sun/chemical exposed areas.
13. Examines the hair, nails, and mucous membranes of
eye, nose, and mouth and anogenital area.
14. Palpates the skin in general and lesions in particular.
15. Applies blunt, linear or shearing pressure to elicit

dermo-graphism or Nikolskys sign.
16. Squeezes, pinches, scratches or rubs the lesion when
required.
17. Performs additional simple procedures like wetting
or oiling the lesion, application of heat or cold, pin
prick test or paring the skin.
18. Does woods lamp examination of lesions.
19. Performs simple microscopy for hair, nail or skin
scrapings.
20. Thanks the patient for his co-operation and asks him
21. Comments on the finding while presenting to the
examiners.
CASE WRITING TIPS

A. Inspection
1. General Survey of the patient:
a. Colour of skin
b. Degree of moisture of skin.
2. Clothings
a Colour
b Design
c Material.
3. Skin lesion
a. Morphology
b. Size
c. Shape
d. Margins/borders
e. Colour
f. Pattern
g. Distribution
h. Hair, nail, mucous membranes.
B. Palpation
1. Pressure
a. Simple
b. Blunt
c. Linear or shearing.
2. Scratching
a. Wetting or oiling the skin
b. Application of heat or cold
c. Pinprick sensation
d. Paring the skin
C. Simple microscopy
a. Hair
b. Nail
c. Skin scrapings
COMMANDS
These ma]y be useful during short cases and may be single
or combined.
For example:
Examine the hand.
Examine the foot.
Examine the arm.
Examine the front or back of the trunk.
After examining the required region, examine the other
related sites, hair, nails and mucous membranes. Perform
simple procedures when required.
CHAPTER 12
Examination of
Musculoskeletal
System
MUSCULOSKELETAL SYSTEM
The musculoskeletal system comprises the following:
i. Joints
ii. Bones
iii. Muscles
Normally this system is not well read by the candidates
and occasionally one can be asked to examine a particular
joint e.g. shoulder, elbow, knee or hip joint.
Sometimes it is asked to demonstrate spinal movements
either at cervical spine or thoracolumbar region.
It is mandatory therefore that all the students should
learn and practice how to examine a joint.
In the examination of musculoskeletal system, good
old principles prevail including inspection, palpation,
movement, measurements and if need be arise one can
go for an X-ray (Certainly not during examination).
The percussion is done to elicit tenderness or to
demonstrate patellar tap. Auscultation is out in this
examination and crepitus in a joint is felt rather heard.
This system is studied as follows:
1. Basic principles
2. Examination of musculoskeletal system as a whole
3. Overview of the musculoskeletal system
4. Commands
BASIC PRINCIPLES
This examination is done as look, feel, move, measure and
X-ray.
Inspection (Look)
For proper inspection, the patient should be appropriately
exposed. It is essential to compare both sides i.e., right
and left and vice versa. The skin should be inspected for
any change in colour, redness, creases, scars, sinuses, and
EXAMINATION OF MUSCULOSKELETAL SYSTEM 323
contractures. The shape of joint should be noted as well.

Any deformity may be either due to postural or structural
defects, paralytic or compensatory. The deformity may be
mobile or fixed and it may be symmetrical or asymmetrical.
The degree of deformity may be mild or severe. The posture
in which limb is placed is also important to note. One
should look for wasting of any muscles or any other
abnormal movements.
Palpation (Feel)
Feeling of the joint should detect warmth due to
inflammation and secondly tenderness. Feeling the skin
with the dorsum of the hand by gently stroking will help
guessing the temperature. Patients face should be watched
during this for any tenderness when he winces with pain.
Any swelling should also be palpated. One should be able
to differentiate between effusion in a joint and synovial
thickening. It is important to feel any altered sensation
in the skin. Synovial thickening has a boggy and soft
character where as effusion is fluctuant and fluid can be
made to shift with in the joint.
Similarly, tenderness and its intensity are palpated.
The crepitus in the joint is also felt by putting one hand
over the joint and moving the joint with other hand.
Similarly, the patellar tap is performed by pressing
gently the patella which displaces the fluid and hits the
femur.
Movements (Move)
Before you check for the movements at a particular joint,
it is mandatory to ask for any pain at that particular joint.
Firstly, it is important to see active movements which the
patient performs without any help. Afterward, passive
movements are checked thoroughly when examiner moves

patients limb at a particular joint to know full range of
movements (ROM). Movements by patient against
resistance elicit tenderness in tendons or muscles at a
particular joint. This is called resisted movement
technique. For this, examiner should know the action of
each muscle and apply appropriate force in opposite
direction of contraction of the muscle. During eliciting
passive movements, it is important to do gently and keep
looking at patients face for any evidence of pain by taking
patient into full confidence. One can elicit full range of
movements. Crepitus can also be felt by performing passive
movements.
Movements involve both neurological and musculo-
skeletal system. Power, tone, coordination and reflexes
have already been discussed in the examination of
neurological system. However, the emphasis is on active
and passive movements measurements.
The candidate should master all the techniques of
assessing active, passive movements and testing power
of the muscle.
Measurements (Measure)
The measurements of the movements at a joint are
important to perform. This indicates the range of
movements at a particular joint provided one knows the
normal movements. Exact measurements are performed by
a goniometer but generally most of the clinicians just
estimate the range of movements at a particular joint by
experience.
EXAMINATION OF MUSCULOSKELETAL SYSTEM

AS A WHOLE (FOR LONG CASE)
The Candidate
light is adequate.
5. Interphalangeal joints
i. Inspects the proximal interphalangeal and distal
inter-phalangeal joints for any deformity.
ii. Checks their active movements (0-90).
iii. Palpates for any tenderness, Haberdens nodes on
distal inter-phalangeal joint.
iv. Checks passive range of movement of these joints
(0-90).
6. Metacarpophalangeal joints
i. Inspects the metacarpophalangeal joint for any
deformity.
ii. Checks their active range of movements (0-90)
and functional disability if any.
iii. Palpates for any tenderness and nodes.
iv. Checks passive ROM at these joints (0-90).
7. Wrist joints
i. Inspects for any deformity.
ii. Checks active range of movement i.e (0-90).
iii. Palpates for nodes, synovial thickening, crepitus
and ganglions etc.
iv. Checks passive range of movement at these joints
(0-90).
v. Elicits signs of carpal tunnel syndrome.
8. Elbow joints
i. Inspects and compares both elbow joints for
nodules, tophi, bursae, carrying angle and tendon
xanthomas.
ii. Performs active range of movements (0-130).
iii. Palpates bursae, nodules, tophi etc, tennis and
golfers elbow.
iv. Checks passive range of movements at these joints
(0-130).
9. Shoulder joints
i. Inspects for wasting deformity or dislocation.
ii. Checks active movements, i.e. flexion, extension,
adduction, abduction and circumduction.
iii. Palpates for tenderness, swelling and crepitus
especially bicipital tendenitis.
iv. Checks for passive range of movement.
10. Temporomandibular joints
i. Inspects for any deformity or swelling.
ii. Checks for active movements by asking him to open
his mouth.
iii. Palpates for dislocation or crepitus.
11. Cervical spine
i. Inspects for deformity or craning.
ii. Checks for active flexion, extension, lateral rotation,
and lateral flexion and notes limitation of
movements.
iii. Palpates for any tender areas and crepitus.
iv. Checks for passive movements in the same way.
12. Thoracic spine
i. Inspects for any deformity i.e., kyphosis, gibbus
or swelling.
ii. Checks for chest expansion and measures it.
iii. Palpates for any tenderness in the spine.
13. Lumbar spine

i. Before checking this makes the patient sit on the
chair so that pelvis is stabilized.
ii. Inspects any deformity i.e., straightening etc. or
any swelling.
iii. Checks for lateral rotation while patient is sitting,
forward flexion and backward extension while
standing up.
iv. Palpates for any tenderness or swelling.
v. Checks for Schobers test.
vi. Makes the patient down supine.
14. Straight leg raising on both right and left legs
15. Sacroiliac joints
i. Inspects for shortening of limb or deformity.
ii. Performs springing of both sacroiliac joints in
supine,
lateral and prone position.
16. Hip joint
i. Inspects the groin and gluteal region.
ii. Cheeks for active range of movement i.e., abduction
(0-60) and adduction. (0-30), flexion (0-90),
extension (0-15).
iii. Palpates for any swellings in groin or gluteal
region.
iv. Checks passive range of movement i.e., abduction,
and adduction, flexion and extension and notes
any restriction of movements.
17. Knee joint
i. Inspects both knees anteriorly, posteriorly for
swelling and position or deformity.
ii. Checks active movements i.e., backward flexion
(which is limited by hamstrings)
iii. Performs patellar tap.
iv. Checks for dimple sign for fluid in the joint.
v. Palpates crepitus, stability. At 15 flexion of the

knee, checks for collateral ligaments and at 80
flexion, while sitting on patients foot for anterior
and posterior cruciate ligaments.
vi. Performs passive movements as mentioned above.
18. Ankle joint
i. Palpates for tenderness, temperature and crepitus.
ii. Inspects medial and lateral malleoli for swelling
or any ankle deformity.
iii. Cheeks for active movements i.e. plantar flexion
(0-30) and dorsiflexion (0-15)
iv. Checks for passive movements i.e. plantar (0-30)
and dorsiflextion (0-15)
19. Mid tarsal joint
i. Inspects any swelling around heal and foot.
ii. Checks for inversion and eversion of foot.
iii. Feels for crepitus, swelling and tenderness.
iv. Checks passive movements by inversion and
eversion.
20. Meta-tarsophalangeal joint
i. Inspects for swelling, guttering, spacing between
two toes (sunray sign).
ii. Checks for active movements i.e., plantar flexion
(0-60).
iii. Palpates swelling in between metatarsals.
21. Toes
i. Inspects for deformity, hammer toe, riding on each
other.
ii. Checks for plantar flexion (0-90).
iii. Palpates for deformity, crepitus, swelling
temperature and tenderness.
iv. Checks passive movements i.e. dorsi-flexion
(0-90).
OVERVIEW OF EXAMINATION OF
MUSCULOSKELETAL SYSTEM
Inspection (Look)
i. Skincreases, scars, colour, erythema, atrophy,
rashes, sinuses.
ii. Shapebone swelling, bursae, swelling, synovium,
effusion, bony alignment, subluxation, dislocation,
shortening, wasting, deformity.
iii. Positionat rest, during activity.
iv. Hand deformitiesswan neck, Boutonnires
deformity, finger drop, mallet finger, Dupuytrens
contracture, Heberdens nodes, Bouchards nodes,
and ulnar deviation.
v. Posturekyphoscoliosis, neurological and myopathic
abnormalities, Trendelenbergs test.
Palpation (Feel)
i. Skinsoft tissue, warmth, coldness, tenderness,
thickening, nodules, over growth, deformity.
ii. Abnormal bursae.
iii. Effusionreducible, fluctuant, ballottable, trans-
illumination.
iv. Fracturestenderness, deformity
v. Palpate and percuss any abnormal nerves.
vi. Map out altered cutaneous sensations.
Movements (Move)
i. Active, passive and resisted movement at each joint.
ii. Pain, power, tone, range, crepitus, creaking, triggering,
locking, hypermobility, telescoping, contractions,
stability.
iii. Fractureabnormality, mobility, crepitus.
iv. Deformitymobile or fixed.

v. Handability to grip, pinch, do up shirt buttons.
vi. Gaitspastic, ataxic, waddling, limp, use of any
mechanical aids.
Measurements (Measure)
i. Range of movements.
ii. Limb circumference from a fixed bony point on each
side.
iii. True and apparent shortening.
X-ray
It is advised to proceed to X-ray of the symptomatic areas
in order to identify abnormal bone and soft tissues.
COMMANDS
Examine this Patients Vertebral Column
The Candidate
modesty.
6. Examines the patient in standing and sitting
positions.
7. Notes any abnormality in the shape of spine.
8. Palpates the spinous processes from above below to
elicit any tenderness.
9. Examines each portion of the spine i.e., cervical,
thoracic lumbosacral and sacroiliac joints.
Cervical Spine
The Candidate
modesty.
6. Asks the patient to touch his chin (flexion80).
7. Asks the patient to look up on the ceiling as far

backwards as possible (extension50).
8. Asks the patient to look over the right and left
shoulders (rotation80).
9. Asks the patient to touch each shoulder with his ears
without liftingup of shoulders (lateral bending45).
NB: Total flexion-extension at cervical spine is 130.
Thoracolumbar Spine
The Candidate
modesty.
6. Examines the patient while he is standing.
7. Asks the patient to touch his toes with knees straight
(flexion0-130).
8. Asks the patient to bend back wards while putting
his hands over his hips (extension0-35).
9. Asks the patient to slide his right or left hand down
his side of the thigh as far as possible (lateral flexion
0-30).
10. Asks the patient to sit on a chair with his arms
crossed over his shoulders.
11. Asks the patient to twist around right and left as far
as possible (lateral rotation0-40).
12. Measures the chest expansion above and below the
nipples with a tape measure to note the movements

of thoracic cage at costovertebral joints.
Elicit Schobers Test

The Candidate
modesty.
6. Notes the position of the dimple of Venus.
7. Draws an imaginary line joining these two dimples.
8. Draws a vertical line of 10 cm above that imaginary
line and 5 cm below that line with a tape measure
while the patient is standing.
9. Asks the patient to bend forwards and measures the
distance between those two points of the vertical line.
10. Notes any increase or no increase in the total distance.
PEARLS
a. In modified Schobers test, a 10 cm line is drawn
vertically above from the imaginary line joining the
two dimples of Venus and asks the patient to bend
forwards. Then measures the length of that line again.
b. He should note whether there is increase in length or

there is no increase at all.
c. Normally after bending forward, the total distance
between two points should increase more than 5 cm.
Demonstrate SLR Test

The Candidate
modesty.
6. Makes the patient lie down in supine position with
both lower limbs in extended position.
7. Lifts the patients right heel with his right hand
making sure the leg is in full extension at knee.
8. Places left hand over the symphysis pubis to stabilize
the pelvis.
9. Keeps moving up wards as much as possible.
10. Asks the patient if he feels any pain.
11. Dorsiflexes the forefoot of the patient by using left
hand.
12. Asks and looks at the patients face for accentuated
pain.
13. Performs the same test on the opposite side and
compares it.
To Elicit Tenderness at Sacroiliac Joints

The Candidate
modesty.
6. Makes the patient lie supine with legs together and
extended at knees and hips.
7. Places ball of thumbs of both hands over the anterior
super iliac spines of the patient and fingers placed
over the lateral sides of the hips.
8. Exerts firm pressure vertically downwards aiming
towards sacrum.
9. Exerts inward pressure from both iliac bones.
10. Turns the patient in right or left lateral position.
11. Places his both hands over the lateral aspect of the
hip and exerts vertical pressure to elicit pain.
12. Makes the patient in prone position.
13. Puts each hand at dimple of Venus.
14. Exerts downward pressure.
PEARLS
The other method is to flex the hip at 90 and exert firm
pressure at the knee through the femoral shaft (only if the
knee in not painful). So, there are four methods to elicit
pain at sacroiliac joint.
Temporomandibular Joint
The Candidate
modesty. (if wearing a veil)
6. Asks the patient to open and close his mouth.
7. Looks for any side to side movement.
8. Places his fingers on the joints on both sides in front
of tragus while the mouth is closed.
9. Asks the patient to open the mouth.
10. Palpates the head of the mandible as it moves
forwards and downwards.
11. Elicits any tenderness.
12. Notes any feeling of clicking in the joint.
13. Notes any other abnormality and compares on both
sides.
PEARLS
TMJ is usually involved late in case of rheumatoid arthritis
when it develops ankylosis.
EXAMINATION OF THE UPPER LIMB

One should do initial few tests to localize upper limb
abnormalities. For this purpose, one can ask the patient
to perform the following tasks:
I. Pick up some object.

II. Write few lines.
III. Put the hands together as if praying.
IV. Comb the hair.
V. Un button the shirt.
Then proceed to full regional examination, which
involves inspection palpation, movements and any other
abnormality.
Assessment of power and any neurological dysfunction
should also be tested.
The movements of shoulder joint are composite and
occur at glenohumeral joint, scapula, clavicle and the
thorax.
In neutral position, the upper arm is adducted at the
shoulder, flexed at the elbow and supinated at the fore-
arm. One should hold the scapula against the chest to
examine the shoulder. Avoid any other movements taking
place at that area.
EXAMINE THE SHOULDER JOINT

The Candidate
6. Notes any swelling or deformity of the joint and
compares on the opposite side.
7. Palpates for any tenderness at sternoclavicular,
acromioclavicular joint and sub-acromial bursa and
the head of humerus.
8. Keeps the shoulder joint in neutral position (The

neutral position of the shoulder is when the upper
arm is adducted at the shoulder, flexed at the elbow
and pronated at the fore arm).
9. Asks the patient to swing the arm forwards (flexion
165o).
10. Asks the patient to swing the arm backwards
(extension65o).
11. Asks the patient to take the arm outwards and
upwards as much as he can (abduction170).
12. Asks the patient to carry the arm forwards across the
front of the chest (adduction50).
13. Asks the patient to scratch the back as up as possible
with his thumb (internal rotation90).
14. Asks the patient to move his arm outwards as much
as possible with elbow flexed (external rotation60).
15. Performs on both sides and compares the findings.
PEARLS
If you ask the patient to the put the hand behind his neck
and go as far as down as possible, it is abduction and
external rotation which is being checked. If you ask the
patient to scratch his back as far up as possible with his
thumb, this is the internal rotation and extension which
are being checked.
EXAMINE THE ELBOW JOINT

The Candidate

modesty.
6. Notes any swelling or deformity of the joint and
compares on the opposite side.
7. Keeps the elbow in neutral position (The neutral
position of the elbow joint is when the arm is flexed
at 90 at elbow and the forearm is in supinated
position.).
8. Inspects the olecranon process for any bursa, tophus,
xanthoma or nodules.
9. Palpates the medial and lateral epicondyles,
olecranon and head of the radius.
10. Palpates ulnar nerve behind the medial epicondyl for
any thickening, also palpates for epitrochlear lymph
nodes.
11. Palpates for tenderness at the lateral epicondyl for
any evidence of tennis elbow.
12. Asks the patient to bend elbow as much as he can
(flexion150).
13. Asks the patient to stretch the flexed elbow
(extension180).
14. Flexes the forearm at 90 at elbow in a semi-prone
position.
15. Asks the patient to rotate the forearm medially
(pronation75).
16. Asks the patient to rotate the forearm outwards or
laterally (supination80).
17. Palpates the radial styloid process during supination.
18. Palpates ulnar styloid process during pronation.
20. Notes any abnormality and comments on the findings.

PEARLS
a. Pronation and supination take place at superior and
inferior radio ulnar joints respectively.
b. The neutral position of the elbow is when the elbow
is flexed at 90o and the arm is supinated.
EXAMINE THE WRIST JOINT

The Candidate
6. Inspects the wrist for any swelling, deformity
erythema or muscle wasting and compares on both
sides.
7. Palpates the wrist with both the thumbs of his hands
by placing them on the dorsum of the wrist and his
fingers holding the ventral part of the wrist
supporting it.
8. Palpates the anatomical snuff box for any tenderness.
9. Asks the patient to approximate the dorsum of his
hands together and flex the wrist joint (flexion75).
10. Asks the patient to put together both the palms then
extend the forearm (extension75).
11. Places together the hypothenar eminences of the
palms which are facing upwards.
12. Asks the patient to move away from the mid line but
keeping in touch the ulnar styloid processes.
(abduction20, also called radial deviation).
13. Asks the patient to keep the same position of palms

but now move in the tips of the fingers which are
touching each other (adduction35, also called
ulnar deviation).
14. Palpates the flexor retinaculum on the volar surface
of the wrist.
15. Percusses the median nerve to produce tingling
sensation in the area of its distribution (carpal tunnel
syndrome).
PEARLS
a. The neutral position of the wrist is with the hand in
the line with the forearm and palm facing downward.
b. Flexor retinaculum is one inch square size and makes
the roof of the carpal tunnel through which flexor
tendons and median nerve pass.
c. The flexor retinaculum is attached proximally to
tubercle of scaphoid and the pisiform bone and distally
to the ridge of trapezium and hook of hammate.
EXAMINE THE METACARPOPHALANGEAL JOINTS

The neutral position of these joints is when the fingers
are in extension.
The Candidate

6. Inspects any swelling, redness, nodules or tophi.
7. Notes any subluxation or dislocation of the proximal
phalanges.
8. Notes any ulnar deviation of the fingers from the head
of the metacarpals.
9. Applies lateral pressure by squeezing the MCP joints
with right hand.
10. Applies anteroposterior pressure over each MCP joint
by both thumbs.
11. Asks patient to bend fingers while keeping it straight
at PIP and DIP joints (flexion90).
12. Asks to hyperextend the fingers while keeping them
straight (extension20).
13. Performs the examination on the other sides and
compares the findings.
PEARLS
In Ehler-Danlos syndrome and other hyperelastoses, the
fingers usually hyperextend in very bizarre posture.
EXAMINE THE INTERPHALANGEAL JOINTS

The Candidate
modesty.

6. Notes any deformity, abnormality, swelling, tophus,
nodules etc.
7. Palpates the sides of the IP joints for any tenderness.
8. Keeps the DIP joint straight.
9. Asks the patient to bend PIP joint (flexion120).
10. Holds the middle phalanx with his thumb and finger.
11. Asks the patient to bend finger at DIP joint (flexion
80).
EXAMINE THE MOVEMENTS OF THE THUMB

The natural position of thumb is when it lies along with
side of the palm and the palm faces upward.
The Candidate
modesty.
6. Notes any deformity, abnormality, swelling, tophus,
nodules etc.
7. Asks the patient to move the thumb away from the
side of the palm in the same plane (extension75).
8. Asks the patient to move the thumb medially over

the palm in the same plane (flexion55).
9. Asks the patient to move the thumb away from the
palm in a vertical plane so that its tip faces the ceiling
(abduction75).
10. Asks the patient to hold tight the thumb against the
radial border of palm (adduction0).
11. Asks the patient to touch the tips of his other fingers
with the tip of his thumb (opposition60).
12. Asks the patient to rotate the thumb in all directions
(circumduction360).
EXAMINE THE HANDS

The golden rule is that before you examine the hands, it
is better to ask whether they are painful or not.
The Candidate
6. Inspects the hand for its size, deformity, wasting of
small muscles, erythema, rashes, and length of fingers,
nails, Dupuytrens contracture and other important
conditions.
7. Asks the patient to extend and flex the fingers

passively and palpates the tendons for any crepitus
or restriction of movements.
8. Asks the patient to make fist.
9. Asks him to extend or flex against resistance.
10. Checks power of interossei muscles by spreading
fingers against resistance and by holding a paper
between the fingers and pulling it out.
11. Asks the patient to flex the MCP at right angle with
extended proximal and distal interphalangeal joint.
12. Checks for presence of functions by hand grip and
pinch grip by asking the patient to hold a glass of
water, undo buttons or to write few lines etc.
13. Performs the examination on the other side and
PEARLS
a. If the examiner asks to exclude the thumb in testing
function of grip, then introduce your two fingers in
patients palm from the ulnar aspect of his hand and
ask him to squeeze them. By doing this, thumb
movement and action is excluded in hand grip.
b. You can describe the rheumatoid hands by saying that
there is bilateral, symmetrical polyarthropathy
involving the small joints of the hands.
EXAMINE THE HIP JOINT

The natural position of hip is in extension with patella
pointing forward (when the patient is standing) and
upwards (when the patient is in supine position).
The Candidate
modesty.
6. Inspects the joints as thoroughly as possible.
7. Looks for the symmetry of the joint.
8. Palpates greater trochanter for any tenderness.
9. Looks at the position of the limb for any deformity.
10. Checks the relative position of the hip joints by placing
thumb on the anteriorsuperior iliac spines and middle
fingers on the greater trochanters.
11. Checks difference in leg length by bending both knees
and feet placed together.
12. Checks flexion by asking the patient to lift his extended
leg as much as possible (active flexion90-100).
13. Checks passive flexion by flexing the knee as well.
(This range is more than active one)
14. Checks for fixed flexion by flexing the normal hip
until the lumbar curve is flattened and to know that
places his left palm under the lumbar spine.
15. Notes degree of elevation of the contralateral thigh.
16. Checks abduction by asking patient to move away
the extended limb from midline as much as possible
and while doing it places left hand over the same
anteriorsuperior iliac spine to stabilize pelvis
(abduction45).
17. Checks adduction by asking patient to move the
extended limb across the midline to the opposite side.
Examiners left hand is placed over the same anterior-
superior iliac supine to stabilize it (adduction30).
18. Checks movements of internal and external rotations

by asking the patient to flex at knees and hips (90)
while the feet and knees are attached to each other.
19. Asks the patient to move apart the knees as far as
possible while keeping the feet together. (external
rotation45).
20. Asks the patient to place his knees and feet in the
previous position and asks him to slide away the feet
as far away as possible but keeping both knees in
contact (internal rotation20).
21. Rotation can also be checked while the limbs are kept
in extension and by asking the patient to rotate the
foot outwards and inwards. It is better to see that
from the foot end of the patient.
22. Checks extension by asking the patient to lie on the
side and move his lower limb backwards as far as
possible or asks him to lie down prone and flex the
knee then lift the knee off the couch as far as possible
(extension10-15).
23. Checks again the movements of both internal and
external rotation in this position.
24. Performs telescoping by gripping the flexed thigh
with both hands and performs pulling movement.
25. Checks any apparent or true shortening of the leg
by asking the patient to lie straight on the bed.
Measures from anteriorsuperior iliac spine to the
medial malleolus for true shortening and for apparent
shortening measures from umbilicus or manubrium
sterni to the medial melleoli.
26. Asks the patient to stand and walk and notes any
tilting of the pelvis by standing behind him
(Trendelenbergs test)

PEARLS
a. Hip joint is covered and surrounded by many
ligaments and thick muscles, therefore inspection of
the swelling may be difficult.
b. Trendelenbergs test: Normally when the person stands
on one leg, the opposite side of pelvis is raised by
abduction at the hip joint of the weight bearing leg.
This is seen when the examiner stands behind the
person and observes an imaginary line connecting both
dimples of Venus. If the patient with diseased hip joint
is standing, then the pelvis drops on the healthy side.
This is called positive Trendelenbergs is test.
c. Internal rotation at 90 flexion is 45 and external
rotation at 90 flexion is 45. Internal rotation in
extension is 35 and external rotation in extension is
45.
EXAMINE THE KNEE JOINT

The natural position of the knee joint is in extension.
Therefore painful knee is always held in flexion.
The Candidate
modesty.
6. Looks at both the knee joints and compares them.

7. Notes skin changes, swelling, deformity, and scars.
8. Looks for quadriceps wasting.
9. Feels for any warmth indicating inflammation.
10. Feels for the surface, margins of patella and lower
end of femur and upper end of tibia along with lateral
joint margin.
11. Feels for the crepitus in the joint by moving it gently.
12. Checks for fluid in the joint by sweeping/squeezing
the skin to produce a bulge around the knee joint.
13. Checks patellar tap by squeezing the lower thigh with
left palm sliding down towards patella. Maintains
that hand just above the upper border of the patella.
Pushes the patella downwards with the right hands
index and middle fingers which produce a bony tap
as the patella touches the underlying femur.
14. Asks the patient to bend his knee to check flexion
(0-135). Listens for any clicks or creaks during
flexion.
15. Places the left fist on the lateral side of the extended
knee pressing vertically the couch. Flexes the knee
to 15. Supports the knee with the left fist and grips
the ankle with right hand and tries to move the tibia
away from the femur (medial collateral ligaments).
16. Places the left fist against the extended knee on the
medial side pressing vertically downwards on the
couch. Flexes the knee to 15. Supports the knee with
left fist and holds the ankle with right hand and tries
to bring the tibia in wards. (lateral collateral ligament).
17. Asks the patient to bend the knee at 90. Places his
right buttock (for right knee examination) on the right
forefoot of the patient.
18. Grips the upper end of calf with fingers of his both
hands while placing his both thumbs side by side
over the tibial tuberosity. Pulls forwards (checks

integrity of anterior cruciate ligament) and pushes
backwards (checks integrity of posterior cruciate
ligament).
19. Performs McMurrays test to elicit any loose bodies
in the knee.
20. Asks the patient to stand up.
21. Looks for any valgus, varus or recurvatum deformity.
22. Observes the gait.
PEARLS
a. Crepitus in knee joint is always felt and not auscultated.
b. During examination, keep on looking at patients face
for any pain.
c. Passive movements are 5 more than active movement
in flexion.
d. There are no extension or rotation movements at knee
joint.
e. Muscle wasting is assessed by measurement as
considered under general examination.
f. McMurrays test: (Right knee joint)
Hold the ankle with right hand.
Hold the knee with left hand.
Flex the knee joint.
With the right hand rotate the foot in clock and
anti-clockwise.
Apply abduction force on the knee by both hands
while doing this manouvre.
While doing this gradually extends the knee from

the flexed position.
Note for any pain or a click or protrusion of a lump
along the joint margin.
PEARLS
Loose bodies or torn cartilages in the joint will be felt as
click, creaks or protrusions through the joint space.
EXAMINE THE ANKLE JOINT

The natural position of ankle joint is straight, in plantar
flexion and slight inversion.
The Candidate
modesty.
6. Looks at both the ankle joints and compares them.
7. Inspects closely the joint for swelling, change in skin
colour, scars, and deformity.
8. Examines the soles for perforating ulcers or callosities.
9. Notes for any small effusion in the joint by looking
in front of both malleoli and on each side of the tendo-
Achilles.
10. Palpates for raised temperature.
11. Palpates for any tenderness or swellings.
12. Asks the patient to bend the foot upward i.e., to raise
the toes towards the knee (dorsiflexion20).
13. Asks the patient to bend the foot downwards i.e., to

move the toes towards the floor (plantar-flexion50).
14. Checks for abduction and adduction.
15. Asks the patient to move the outer part of sole inwards
(inversion30).
16. Asks the patient to move inner part of the sole
outwards (eversion-5).
PEARLS
a. Dorsiflexion and plantar flexion occur at ankle joint.
b. Inversion and eversion take place at subtalar joint.
c. Transmitted impulses may be obtained between the two
sides of tendo-Achilles if sufficient fluid is present in
the ankle joint.
d. Look for hallux valgus, claw foot and Charcots joint
and abnormalities of transverse or longitudinal arches.
e. Palpate sole for deep tenderness especially for the
calcaneal spur.
EXAMINE METATARSOPHALANGEAL JOINTS

The Candidate
modesty.

6. Looks for any deformity on the dorsal and plantar
aspect of the foot.
7. Holds the forefoot across metatarsophalangeal joints
with thumb and finger of his hand and squeezes
across.
8. Assesses metatarsophalangeal joints individually.
9. Asks to bend upwards the great toe (dorsiflexion
60).
10. Asks the patient to bend his toes downwards (plantar
flexion40).
EXAMINE INTERPHALANGEAL JOINTS OF THE FOOT

The Candidate
modesty.
6. Looks for any abnormality.
7. Palpates for any tenderness, or increase in
temperature.
8. Asks the patient to bend and spread his toes (fanning)
abduction.

Inversion of heel is 20 and eversion is 10. Total supination
at forefoot level is 35 whereas total pronation is 20.
As regards great toe, extension at MPJ is 90, and
extension is 65. Flexion at IPJ is 60 where as extension
at the same joint is 0.
355
PATIENTS RECORD
CHAPTER 13
Patients
Record
It is very important to keep the patients record in the form

of notes accurately, legibly and in a systematic way. This
will provide very vital information later on as a record
of what were the problems, what actions were taken and
what improvement occurred and what was the ultimate
outcome.
These notes should be complete and comprehensive
as much as possible so that if another person wants to
go through them, he should not face any difficulties or
hurdles in getting the whole scenario and history of the
patient. All these documents have to be confidential as
they may have some medicolegal implications.
The daily progress notes should be written with date
and time in the corner and SOAP methodology should
be adopted where S indicates subjective symptoms, O
indicates objective assessment by the physician, A
indicates overall assessment and P indicates the further
planning for the management of the given problem. The
notes should be written legibly and at the end the doctor
should put his name or signature and should also put
a stamp showing his full name and title i.e., HO, SHO,
registrar or senior registrar etc.
Simple diagrams can be used to quickly highlight the
underlying problems in a system. Measurements should
be added when required.
Avoid using abbreviations and short hand as this may
cause a lot of confusion. Each discipline has its own
language but the notes should always be meaningful to
all health care workers who need to read them.
Summary of the problems should be written after each
comprehensive history and examination and one should
also mention in order of preferences the differential
diagnosis. Therefore, appropriate investigations are sent
to include or exclude other diagnoses as multiple
pathologies may also co-exist.
PATIENTS RECORD 357
Having done this, one writes appropriate treatment

plan for the most probable diagnosis on a properly printed
doctors order sheet and on the treatment chart.
It is very vital that a comprehensive note should be
made in the notes for all procedures either minor or major
performed on the patient and the exact time and date
should be mentioned along with the name and designation
of the person who did the procedure. This practice helps
the next on duty doctor to assess the importance of the
results if they have not come through yet e.g., cerebrospinal,
pleural and ascitic fluid.
Notes are written in a meticulous way mentioning
patients daily progress during his stay in the hospital.
At the time of discharge from the hospital, a detailed
proforma is filled in mentioning the problems and
investigations performed or pending and treatment to take
home along with a brief summary. This is an important
document as whereever the patient goes he will have to
produce this for a quick reference of his current and past
ailments and to produce when the patient comes to attend
as an out patient for follow up and quickly the problems
and plan for further follow up is outlined without
unnecessary delays or hurdles. It is, therefore, very
important that such a discharge summary should be
written with great caution and important informations
should not be missed.
The record of out patient attendance should also be
kept in an organized way in folders which are properly
labeled and either these folders are different folders or the
ones kept with the folders having patients record when
he was admitted as an inpatient.
359
INVESTIGATIONS
CHAPTER 14
Investigations
After taking a detailed history and performing a general

physical and detailed systemic examination, one reaches
to a most probable diagnosis and a list of common
differential diagnoses is made, the step of sending
appropriate investigations comes there after.
The term routine investigations has to be justified
and each investigation has to be weighed as regards its
significance and implication in the management of the
patient. Investigations are performed to include or exclude
diagnosis. Before asking for investigations, clinician should
know the cost effectiveness as well. Try to order as
minimum investigations as possible but this does not mean
that important investigations should not be asked for even
if they are expensive.
In the FCPS, MRCP (UK) examinations, during the
theory paper if the examiner has asked investigations, then
their number is also specified e.g., give three or four
investigations and you have to write the most relevant
investigations in order and you have to justify why are
you asking for them?
The clinical accuracy is the most important pillar of
medicine and unnecessary investigations should not be
asked or ordered. This implies especially in our socio-
economic set up where economy plays an important role
as all the patients cannot afford all the investigations if
written without taking into consideration the social status
and income of the patient.
If investigations are ordered without any basis for
diagnosis, it leads to collection of a number of irrelevant
information which further can muddle the actual
diagnosis. If in doubt about whether or not to perform
a test, the clinician should ask himself or herself whether
knowledge of the information obtained will influence the
patients management.
INVESTIGATIONS 361
This chapter is written to cover some most important

investigations symptomwise. Most sophisticated and
comprehensive investigations can be looked into standard
text books for more details. Only the headings of
investigations are listed systemwise.
PEARLS
Sometimes investigations which are asked in the examination
can be grouped as radiological investigations including,
CXR, U/S, CT or MRI or haematological investigations
including CBC, ESR, peripheral picture and DLC etc.
Let us discuss first routine investigations:
ROUTINE INVESTIGATIONS
1. Complete blood count (CBC)
2. ESR
3. Peripheral blood picture
4. Urea, creatinine and electrolytes
5. Urine routine examination
6. Blood sugar both fasting and random
7. Lipid profile after 14 hours of over night fasting
8. Liver function tests
9. Chest X-ray PA view
10. ECG.
PEARLS
Not all the above investigations are required in every case
but these are the usual ones which one should know and
depict quite a few abnormalities as regards investigations
are concerned.
SYSTEMIC INVESTIGATIONS
A. Cardiovascular system investigations
1. Electrocardiogram (ECG)
2. Exercise tolerance test (ETT)
3. 24 hours holter monitoring
4. Echocardiography
5. Radio isotope ventriculography
6. Thallium stress test
7. Cardiac catheterization
8. Coronary angiography
9. CT scan with multiple slices.
B. Respiratory system investigations
1. Chest radiography
2. Sputum examination for colour, micro-organisms,
AAFB and malignant cells
3. Pulmonary function tests including:
PEFR (peak-expiratory flow rate) FEV1, FVC
4. Estimation of lung volume
5. Diffusion capacity of the lung, DLCO
6. Arterial blood gases
7. Bronchoscopy
8. Transbronchial lung biopsy
9. Bronchoalveolar lavage/washing/brushing
10. Open lung biopsy
11. Transthoracic lung biopsy
12. Pleural aspiration
13. Pleural biopsy
14. Thoracoscopy
15. Mediastinoscopy
16. CT chestHigh resolution (HRCT)
17. Ventilation perfusion scan
18. Bronchography
19. Spiral CT scan.
INVESTIGATIONS 363
C. Immunological investigations
1. Mantoux test
2. Kveim test
3. Intradermal allergen test
4. Precipitin tests
5. Bronchial challenge tests.
D. Gastrointestinal investigations
1. Stools examination for ova and cysts, occult blood
2. Plain radiography
3. Barium swallow
4. Barium meal and follow through
5. Small bowel enema
6. Barium enema
7. Upper GI endoscopy and biopsy
8. Rigid procto-sigmoidoscopy and biopsy
9. Flexible sigmoidoscopy and biopsy
10. Colonoscopy and biopsy
11. Endoscopic retrograde cholangiopancreaticography
ERCP
12. Gastric function tests
13. Faecal fat excretion
14. Xylose excretory tests
15. Lactose tolerance test
16. Radioisotope breath test
17. Hydrogen breath test
18. Urease test, CLO test
19. LFTs: ALT, AST, alkaline phosphatase, albumin,
globulin, bilirubin, gamma GT, prothrombin time,
activated partial thromboplastin time
20. Alpha fetoprotein
21. Antinuclear antibody
22. Antismooth muscle antibody test
23. Antimitochondrial antibody test
24. HBsAg, Anti HCV Ab, Anti HAV IgG and IgM , Anti
HEV IgG and IgM and other related markers
25. Ultrasound scanning
26. Liver biopsy
27. Radio-isotope scan
28. Trans jugular intrahepatic portosystemic shunt-stent
and surgery TIPSSS
29. Magnetic resonance cholangiopancreaticography
MRCP
E. Urogenital/nephrological investigations
2. Urea and creatinine
3. Creatinine clearance
4. Renal scan
5. Ultrasound scan
6. EDTA/DTPA scan
7. Intravenous urogram IVU
8. CT
9. MRI
10. Angiography
11. Renal biopsy
12. Cystoscopy.
F. Endocrinological investigations
a. General
1. Blood glucose, fasting/random
2. Oral glucose tolerance test (OGTT)
3. Glycosylated haemoglobin (HbA1c)
5. Insulin and C-peptide levels.
b. Thyroid
1. FT3, FT4
2. TT3, TT4
3. TSH
4. Antibodies to thyroglobulin/microsome
INVESTIGATIONS 365
10. Radioisotope scan of the thyroid

11. Ultrasound scanning
12. Fine needle aspiration and cytology (FNAC).
c. Adrenals
1. Serum sodium and potassium
2. Cortisol level at 9.00 AM
3. Short synacthen test
4. Urinary 24 hours VMAs
5. Urinary metanephrins
6. Plasma catecholamines
7. ACTH levels
8. Small dose dexamethasone suppression test
9. High dose dexamethasone test
10. Ultrasound examination
11. CT, MRI
12. Digital subtraction scintigraphy
13. Methyl iodo benzyl guanidine scan (MIBG) scan
14. Selective venous sampling.
d. Diabetes
1. Insulin tolerance test
2. Oral GTT
3. Growth hormone level
4. X-ray skull lateral view
5. MRI.
e. Urogenital
1. LH, FSH
2. Oestradiol, testosterone.
f. Parathyroid
1. Serum calcium and phosphorus
2. Alkaline phosphatase
3. Urinary hydroxy proline
4. Parathyroid hormone (PTH)
5. Urinary calcium
6. Bone biopsy.
G. Rheumatological investigations
1. Uric acid
2. ESR
3. Antinuclear antibodies (ANA)
4. Rheumatoid factor (RA)
5. Extractable nuclear antigens (ENA)
6. X-ray joints
7. Synovial fluid examination
8. Microscopy of synovial fluid
9. Anti-neutrophilic cytoplasmic antibodies (cANCA)
and (pANCA)
H. Neurological investigations
1. Lumbar puncture
2. CT/MRI
3. Electroencephalogram EEG
4. Sensory visual evoked potential (VEP)
5. Nerve conduction studies (NCS)
6. Electromyography (EMG)
7. Radioisotope brain scan
8. Myelography
9. Muscle biopsy
10. Peripheral nerve biopsy
11. Cerebral angiography
12. Digital subtraction angiography
13. MRI angiography
14. Brain biopsy.
I. Haematological investigations
1. Full blood count
2. Peripheral blood film
3. Blood volume
4. Bone marrow aspiration, trephine biopsy
5. Carboxy haemoglobin
6. Cell marker studies
INVESTIGATIONS 367
7. Chromosome analysis (karyography)

8. Cytochemistry
9. Acid phosphatase
10. Neutrophilic alkaline phosphatase
11. 2,3-Diphosphoglyceridase
12. Glucose-6-phospahte dehydrogenase (G-6-PD).
INDEX
A Bells phenomenon 201

Ah test 208 Biceps brachii 227
Abdominal distension 125 Biceps jerk 267
Abdominal reflexes 258 Bjerrum screen 186
Abductor digiti minimi 233 Blood pressure 50
Abductor pollicis brevis 236
Brachioradialis 229
Abductor pollicis longus 236
Abductors of the hips 245 Breasts 57
Accessory nerve 209 Brings sign 262
Accommodation reflex 188 Bulbocavernosus reflex 260
ACTH 206 Bulk of muscle 215
Adductors of the hips 244
Adies pupil 189 C
Agnosia 179 Caloric test 205
Ankle clonus 279 Caput medussae 154
Ankle jerk 271
Ankle joint 351 Cervical spine 331
Anosognosia 180 thoraco-lumbar spine 332
Aortic regurgitation 117 Schobers test 333
Apraxia 178 Chaddiks sign 262
Apex beat 105, 111 Claw foot 252
Argyll Robersons pupil 189
Clonus 278
Ascites 149
Auditing 12 Clubbing grades 40
Auscultation of the chest 83 Cochlear part, 8th nerve 202
Auscultation of the pre- Coin test 91
cordium 113 Corneal reflex 198
Avoidance reflex 302
Corrigans sign 117
B COWS 206
Babinskis sign 262 Cremasteric reflex 258
Ballottement 128 Cullens sign 131
Base of the heart 120 Cyanosis 39
D First palmar and dorsal

Deep pain 283 interossei 235
Deformities of chest 79 Flexor carpi radialis 232
Deltoid 221 Flexor carpi ulnaris 232
Demussets sign 117 Flexor digitorum profundus
234
Diaphragm 243
Flexor digitorum superficialis
Diaphragmatic palsy 88
233
Digital rectal examination 154
Flexor pollicis longus 239
level of consciousness 176
Flexors of the knee 248
memory 176
Flexors of the thigh 246
speech 177
Fundoscopic examination 190
Dipping method 128
Dorsiflexor of the ankle 249 G
Durozies murmur 118 Gallop rhythm 116
Dysdiadochokinesia 255 General physical examination
27
E
Glabellar tap 304
Elbow joint 338 Glossopharyngeal and vagus
Elliss curve 86 nerves 206
Engorged abdominal veins Gordons sign 262
153 Gaudas sign 262
Eversion inversion 250 Graphaesthesia 293
Extension pollicis brevis 239 Grasp reflex 302
Extension pollicis longus 238 Grey-Turners sign 131
Extensor carpi radialis longus
H
231
Extensor carpi ulnaris 230 Harrisons sulcus 79
Extensor digitorm longus 252 Heel shin test 256
Extensor digitorum 231 Hills sign 118
Extensor hallucis longus 252 History taking 13
Extensors of the knee 248 allergy history 15
Extensors of the thigh 246 drug history 15
family history 15
F menstrual history 15
Facial nerve 199 past medical history 15
Finger flexion jerk 273 personal history 15
INDEX 373
present illness 14 Lumbricals 235
social history 15 Lymphadenopathy 42
Hoffmans sign 274
Holmes-Adie syndrome 189 M
Horners syndrome 189, 212 Medical education skills 10
Hypoglossal nerve 210
clerical skills 11
I clinical skills 10
Ilio psoas muscle 243 communication skills 10
Infraspinatus 222 ethical skills 11
Inspection of the chest 78 organizational skills 11
Instruments required 23
procedural skills 12
Interossei (dorsal) 240
Interossei (palmar) 240 Menace reflex 186
Inter-phalangeal joints of Metacarpo-phalangeal joints
foot 353 341
Inter-phalangeal joints 325 Meta-tarso-phalangeal joints
Ishiharas chart 183 352
Movements of the thumb
J
343
Jaegers chart 183
Mullers sign 118
Jaundice 41
Jendrassiks manoeuvre 264 Murmurs, grading 99
Jew jerk 266
N
JVP 107
Negative data in history 16
K
Nutritional status 37
Knee jerk 269 Nystagmus 195
Knee joint 348
Grading of 196
Kochers test 57
Krotokoffs sounds 53 Congenital 196
Kussmauls breathing 66 Travellers 196
Kussmauls sign 108
O
L
Ocular movements 192
Latissimus dorsi 224 Oedema, fast 46
Light reflex 187 Oedema, slow 46
Lovibond angle 40 Olfactory nerve 181
Oppenheims sign 262 S

Opponens pollicis 237 Sacroiliac joints 335
Optic nerve 182 Sartorius 244
Scalene lymph node 45
P
Schaefers sign 262
Pain 307 Schamroths sign 40
Pallor 38 Schobers test 36
Palmomental reflex 301 Sense of joint position 287
Palpation of the chest 76, 79 Sense of vibration 285
Patellar clonus 278 Sensory inattention 294
Pectoralis major 226 Serratus anterior 225
Pembertons sign 57 Shoulder joint 337
Percussion of the chest 75, 81 Signs of cardiac failure 119
Plantar flexion of the ankle 249 SLR test 334
Pleximeter 68 Small intrinsic muscles 251
Plexor 68 Snellens chart 184
Power of muscles 218 Snout reflex 303
Primitive reflexes 173 Spinal percussion 90
Puddle sign 151 light 90
Pulse 46 heavy 90
Spinal tenderness 90
carotid 47
Squint 189
collapsing (water-
Stereognosis 292
hammer) 49
Stethoscope 88
paradoxus 49
Subscapularis 223
radial 46
Succession splash 87
Q Suckling reflex 303
Quinkes sign 118 Superficial anal reflexes 260
Supinator jerk 268
R Supinator 228
Reinforcement 248 Supraspinatus 222
Reviews 12 Systemetic review in 16
Rhomboids 223 cardiovascular system 16
Rinnes test 172 central nervous system 18
Rombergs sign 289 dermatological system 20
Rotators of the thigh 247 endocrine system 20
Routine investigations 361 gastrointestinal system 17
INDEX 375
haematological system 18 Touch 281
locomotor system 19 Tracheal position 86
respiratory system 16 Tracheal tug 85
urogenital system 17 Triceps jerk 268
Triceps, muscle 228
T Trigeminal nerve 196
Tactile discrimination 291
U
Tactile localization 290
Tandem walking 36 Upper limb 336
Taste sensation 201 V
Teeth 126
Vestibule-cochlear nerve 188
Temperature, sensation 284,
285 W
Temperature 54 Waldayers ring 45
Throat 60 Wartenbergs sign 275
Thyroid 55 Webers test 172
Tone of muscles 216 Wrist clonus 279
Tongue 61 Wrist joint 340

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Step by Step

Clinical Examination Skills

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Step by Step Clinical Examination Skills

2009, Farrukh Iqbal

I am delighted to write a Foreword to this book which

I have full confidence that this book will receive respect

The field of medical science is extremely vast and it

I feel immense pleasure to thank all my teachers,

Case Writing Tips ................................................... 133

Signs of Meningeal Irritation ................................ 299

Bibliography ....................................................................... 369

The value of clinical medicine cannot be denied even in

ailment and this further builds the confidence of the patient

It is also important to know that various teachers have

This book will not only enhance the clinical knowledge

spend your time honestly with the patients and practice

management to follow later. If you want to become an

When a new medical graduate is given responsibilities

History taking is the foundation pillar of patients manage-

HISTORY OF PRESENT ILLNESS

PAST MEDICAL HISTORY

PERSONAL AND SOCIAL HISTORY

DRUGS AND ALLERGIES

It is often useful to see the pills oneself if the patient has

Central Nervous System (CNS)

a good history. Many nebulous terms are used in

As mentioned before, prior to clinical examination, you

1. Small Snellens chart 11. Thermometer

The physical examination is divided into:

GENERAL INSTRUCTIONS FOR CONDUCTING

GENERAL PHYSICAL EXAMINATION

Even talking to the patient may reveal a number of

9. Examines the head for any abnormality and feels for

23. Palpates the neck for thyroid swelling or cervical

40. Thanks the patient at the end of the examination for

CASE WRITING TIPS

STEP BY STEP EXAMINATION OF THE PATIENT

25. Auscultates over other areas if indicated (for any

41. Checks for springing of sacroiliac joints.

63. Measures height and weight if desired.

GENERAL PHYSICAL EXAMINATION

GENERAL PHYSICAL EXAMINATION COMMANDS

Look for Pallor

Look for Cyanosis

Look for Clubbing

Look for Jaundice

8. Examines the palms and the skin.

Check for Lymphadenopathy

11. Palpates the lymph nodes on that side by pushing

Check Lymph Nodes in Axilla

11. Abducts patients right arm and rests patients right

Check Lymph Nodes in the Inguinal Region

12. Comments on the findings while presenting to the

Look for Peripheral Oedema

3. Exposes the patient adequately, observing the

CHECK PERIPHERAL PULSES

3. Exposes the patient adequately, observing the

3. Exposes the patient adequately, observing the

Check Collapsing (water hammer) Pulse

Check Pulsus Paradoxus

3. Exposes the patient adequately, observing the

3. Exposes the patient adequately, observing the modesty.

21. Checks the blood pressure in supine and standing