2. BY
DR ABDUL SAMI
MPHIL EASTERN MEDICINE
The Islamia University of Bahawalpur
Pakistan

3.  INTRODUCTION
 GENERAL EXAMINATION
 LOCAL EXAMINATION

4. 1. Wash hands.
2. Introduce yourself.
3. Confirm patient details – name / DOB/sex
4. Explain the examination.
5. Gain consent.
6. Expose patient’s chest & abdomen.
Ask if patient has any pain

5.  HANDS
Clubbing – inflammatory bowel disease / cirrhosis / coeliac
disease
Koilonychia – spooning of the nails – chronic iron deficiency
Leukonychia – whitened nail bed –
hypoalbuminemia – liver failure / enteropathy
Palmar erythema – reddening of palms – liver disease /
pregnancy

6.  Axilla
Lymphadenopathy – malignancy / infection
Hair loss – malnourishment / iron deficiency anaemia
 Icterus
Jaundice – noted in the sclera – haemolysis / hepatitis
/ cirrhosis, biliary obstruction

7.  Inspection
 Palpation
 Percussion
 Auscultation
 Rectal examination

9. Examination of :
1- Oral cavity.
2- Abdomen.
3- Rectum.

10. Lips
Gums
Teeth
Tongue
Palate
Breath

11.  Color
• Blue
• Pale Cyanosis Anemia
 Ulceration
• Syphilis
 Inflammation
• Iron deficiency

12.  Colour
Blue line(Lead poisoning)
 Bleeding
Acute leukemia
 Swollen
Scurvy
Pregnancy

13. Teeth
Hutchison’s teeth
(Congenital syphilis)
Tongue
Colour
Blue (cyanosis)
Red (Nicotinic poisoning)
Pale (anemia)
Black (taken iron supplement)
Blue tongue

14.  Tremors
Nervousness, Parkinsonism
 Size of tongue
Macroglossia (cretins) Tremors Dry
 Surface of tongue
Dry tongue (dehydration)
Bald tongue (Anemia)
Furred tongue Macroglossia smooth
(smoking, mouth breathing)
Ulceration
(Whooping cough, T.B.) Macroglossia
furred ulceration

15. ABDOMINAL
EXAMINATION

16. I. Inspection
II. Palpation
III. Percussion
IV. Auscultation
Inspection
Visual observation of the body in the course of a medical examination.
Contour of the abdomen
Flat Rounded
Scaphoid protuberant

17. Movements of the abdomen
Abnormal movement (Appendicitis ,Peritonitis)
Bulging
Left abdomen (spleen)
Right abdomen (liver)
Lumber region (kidney)
Pulsation in abdomen bulging
Epigastrial pulsation in
(Nervousness Enlarged right ventricle)
Prominent veins
( Portal hypertension ,Obstruction of inferior vena cava)
Pigmentation of abdomen wall
( chronic pancreatitis , Addison disease)

18. Peristaltic waves
Obstruction, inflammation
Pubic hair
Male pattern (convex)
Female pattern (concave)
Umbilicus
• position
Normal (central)
Ovarian tumour (Shifted upward)
• Shape
Inverted (normally)
Evertion/ ptosis (asites & hernia)
Scars and striae
• Pinkish (Cushing’s syndrome)

19. Physical examination in medical diagnosis by pressure of the hand or
fingers to the surface of the body especially to determine the condition (as of size or
consistency) of an under lying part or organ .
Types
i. Superficial
ii. Deep
iii. Bimanual
iv. Dipping
Superficial
It should be graded as follows:
Grade1 (pain on touching)
Grade2(facial expression shows feeling
of pain)

20. Grade3 (patient move his diseased part when touched)
Grade4 (not allow the doctor to touch)
Palpable mass
Area
Number
Size
Mobility
Pulsation
Location
 Scheme for palpation of abdomen
Left iliac fossa.
Left lumber area (for left kidney)
Left hypocondrium(for spleen)
Right lumber area (for right kidney)
Right hypochondrium(for liver & gall bladder)
Right iliac fossa & hypogastrium(for urinary bladder & uterus)
Umbilical area(for aortic ,Para-aortic & mesenteric lymph node)

21. Liver
 Standard Method
The patient must be lying in the supine position with hip
and knee flexed.
Ask the patient to take a deep breath.
The examiner moves his right hand from the right iliac
Fossa gradually upwards until you may feel the edge of the liver.
 Alternate Method
This method is useful when the patient is obese.
Stand by the patient's chest.
“Hook" your fingers just below the costal margin
and press firmly.
Ask the patient to take a deep breath.
You may feel the edge of the liver press against your fingers

22.  In the liver we palpate the
Character of edge (smooth,sharp,irregular or thickened)
Surface of liver (smooth or nodular)
Tenderness (Liver congestion, infective hepatitis)
Pulsation (Tricuspid Incompetence)
Spleen
Spleen can be palpated by the following methods
Classical method
The patient is put in the supine position and palpated from the right iliac fossa to the left
hypochondriac region. The edge of the spleen may be felt on deep inspiration.
Bimanual method
The patient is put in the right lateral position, one hand of the examiner is put over the lower chest
and the spleen is palpated with the other hand. A soft spleen which may be missed by classical method
may be palpated by this method.
Hooking method
The patient is put in the right lateral position and the examiner stands on the left side and feels the
spleen by hooking his fingers over the left costal margin.

23. Dipping
This method is used when there is severe ascites which may mask an enlarged spleen. The patient is
put in the supine position and examiner palpates as in the classical method except that he dips his
fingers into the abdomen with each palpation, so that the fluid is displaced temporarily to the side
facilitating palpation of the spleen.
Gall Bladder
The gall bladder is normally not palpable. When distended, it is palpated as a firm, smooth, rounded or
globular swelling with distinct
borders just lateral to the rectus abdominis muscle.
Causes of enlarged gall-bladder
Carcinoma of the head of the pancreas
Carcinoma of the gall-bladder
Malignant obstruction of the common bile duct.
Murphy’s sign
Ask the patient to take breath and the same time the
Finger are pressed upward underneath the right costal margin.
The gall bladder will move down as diaphragmatic descends during Inspiration.
Courvoisier’s Law
In jaundice gall bladder will not palpable because due to chronic inflammation
It’s walls will become fibrotic.

24. The patient is put in the supine position, without pillow, with his knees flexed.
Both kidney are palpated by standing on respective side i.e., on left side to
Palpate left kidney & on right side to palpate right kidney. First palpate left kidney and then
right.
Left kidney
The left kidney is palpated by keeping the left hand
Posteriorly in the loin and the right hand anteriorly
In the left lumbar region. Then the patient takes a
Breath, the left hand is pressed forward and the right
Hand backwards, upwards and inwards.
Right kidney
The right kidney is likewise are not palpable because of overlying liver , unless placed low in
position or enlarged. Its lower pole is felt as a rounded firm swelling between both the hands and
can be pushed back and forwards between two hands. This procedure is called “balloting”.

25. Patient should be made to sit on the bed with back toward the doctor.
Now with the thumb, a sudden “punch” is given at the angle between the
vertebral column and last rib (renal angle). And palpate the tenderness.
Psoas Sign
This is a test for appendicitis.
Place your hand above the patient's right knee.
Ask the patient to flex the right hip against resistance.
Increased abdominal pain indicates a positive psoas sign.
Obturator Sign
This is a test for appendicitis.
Raise the patient's right leg with the knee flexed.
Rotate the leg internally at the hip.
Increased abdominal pain indicates a positive obturator sign

26. The act or technique of tapping the surface of a body part to learn the condition
of the parts beneath by the resulting sound.
Commonly three method are used for percussion
Fluid thrill method
Shifting dullness
Cystic thrill
Puddle sign
Fluid thrill method
Patient in supine position
Ask an assistant to place the ulnar Border
of his hand vertical in the midline over the anterior abdomen wall.
Place one hand on the left flank and flick or tap the opposite flank.
A fluid thrill or wave is felts a definite and unmistakable impulse by hand over
the patient’s left flank.

27. Fluid thrill is felt only when there is a large amount of ascitic fluid which is
under tension.
Shifting dullness
 Patient in supine position
 Percuss laterally from midline keeping
finger in longitudinal axis until dullness is detected.
 Keep the hand there & ask the patient to turn on
other side.
 Percuss again in this new position.
 If the dull note has become resonant then ascitic
fluid is probably present.
 Repeat the method on the opposite side for confirmation.
Cystic thrill
 Patient in supine position.
 Put three finger index , middle & ring finger of left hand over swelling.
 Index and ring finger should be adherent to the skin.
 Now with middle finger of right hand strike the middle finger of left hand.
 In this , a thrill will be felt by other two fingers which were kept adherent to
swelling.

28. Puddle sign
 Patient in knee-chest position so that fluid gravitates down to
The anterior abdomen wall.
 The stethoscope is placed over the abdomen in the midline and the
Anterior abdominal wall is flicked for a puddle sound.
 Can detect small quantities of fluid as much as 120 ml.
Auscultation
The process of listening to sounds that are produced in the body.
Types
Direct auscultation
Indirect auscultation
Sound
 Normal (Gurgle) 7-8 /min.
 Increase (intestinal obstruction)
 Absent (Paralytic ileus)
 Succussion splash

29.  Bowel sounds
 Normal – gurgling
Abnormal – e.g. “tinkling” (bowel obstruction)
Absent – ileus / peritonitis
 Bruits
 Aortic bruits – auscultate just above the umbilicus
Renal bruits – auscultate just above the umbilicus,
slightly lateral to the midline

30.  Normally done in
 Acute abdomen
 Chronic constipation
 Rectal bleeding
 Look for
 Inspection of the anal region is done in a good light.
 By placing the patient in semi-prone position.
 A glove lubricated finger is put into the anal canal and
palpation is done for
New growth
Thrombosed pile
Ulcer
Enlargement of prostate