Bedside techniques .pdf free download

Fourth Edition
Muhammad Ina�
Shabbir Ahmed Nasir

. ESSENTIALS O-F ·.
I EREN IAL
DIAGNOSIS
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BEDSIDE
TECHNIQUES
Methods of Clinical Examination
Fourth Edition
A book for medical st1.1dents and doctors
by
Muhammad lnayatullah
FRCP(Lond)
Professor ofMedicine
Nishtar Medical College, Multan
Shabbir Ahmed Nasir
FRCPE
Principal
Multan Medical and Dental College, Multan
Paramount Books (Pvt.) Ltd.
Karachi ILahore IIslamabad IHyderabad IFaisalabadIPeshawarIAbbottabad I

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©Paramount Books (Pvt.) Ltd.
Bedside Techniques
Methods ofclinical Examination
by
Muhammad lnayatullah
ShabbirAhmed Nasir
All rights reserved. No part of this publication may 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 permission of the Copyright holders.
This book is sold subject to the condition that it shall not, by way oftrade or otherwise, be lent, resold,
hired out or otherwise circulated without the publisher's prior consent in any form of binding or cover
other than that in which it is published and without a similar condition including this condition being
imposed on 'the subsequent purchaser.
Medical knowledge is constantly changing. As new information become available, changes in
treatment, procedures, equipment and the use of drugs become necessary. The editors, contributors
and the publishers have, as far as it is possible, taken care to ensure that the information given in this
text is accurate and up-to-date. However, readers are strongly advised to confirm that the information,
especially with regard to drug usage, complies with the latest legislation and standards ofpractice.
Copyright � 2013
All Rights Reserved
Fourth Edition .............. 2013
Reprint ............................ 2014
Reprint ............................ 2015
,.
.Paramount Books (Pvt.) Ltd.
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Fax: 34553772. E-mail: paramount®cyber.net.pk
Website: www.paramountbooks.com.pk
ISBN: 978-969-494-920-8
Printed in Pakistan

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Dedicated to our teachers

CONTENTS
Int:roduction.................................... l Summary of Examination......80
t. History Taking and Physical Peripheral Arterial System................81
Examination................................... Z
Peripheral Venous System..................82
Routine Questio11s
About Cardinal Symptoms................6
Writing Out Routine
Examination............................................82
Writing Out the Examination........14
3. Respiratory System .....................83
General Physical Examination.....14
Anatomical Considerations...............83
Summary of Gene:r:al
Physical Examinabon..................29 Surface Anatomy...............................83
WritingOut Routine Symptoms..............................................................83
Examination............................................32 Cough...............................................................83
2. Cardiovascular System ..............33 Sputum...........................................................84
Symptoms..............................................................33 Hemoptysis...............................................84
Dyspnea........................................................33 Chest Pain...................................................84
Chest Pain...................................................34 Dyspnea ........................................................85
Palpitation..................................................34 Wheeze...........................................................85
Examination.......................................................34 Stridor..............................................................85
Examination of Pulse....................34 Symptoms of Upper
Measurement of Blood Respiratory Tract Disease........85
Pressure.........................................................43 History................................................:......................85
Neel< Vcins.................................................45 Examination.......................................................86
Examination of Precordium.............49 Position of the Patient..................86
Inspection...................................................49 Inspection...................................................87
Palpation......................................................53 Palpation......................................................90
Percussion...................................................53
Percussion...................................................93
Auscultation............................................53
Auscultation............................................96
Signs of Rheumatic and
Congenital Heart Diseases........65
Summary of Examination......103

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Writing Out Routine
Exa1nination............................................l04
4. Alimentary and Genito-
Urinary System ............................. 107
Symptoms............................................................�.107
AlimentarySystem.........................107
Genitourinary System..................110
Examination.......................................................111
Oral Cavity....................,...........................111
Examination of Abdomen.......113
Writing Out Routine
Examination............-...........................,...133
s. Nervous System .............................135
1-Iistory.......................................................................135 ,
Symptom.s...................................................135
Applied Anatomy and
Physiology.........................................,...................136
Examination.......................................................143
Higher Menta1 Functions.........143
Speech..............................................................145
Cranial Nerves.......................................152 ·
Motor System..........................................177
Localization of Motor
Lesion...............................................................197
SensorySystem.....................................201
Localization of Sensory
Lesion..............................................................206
Miscellaneous Tests........................208
WritingOut Routine
Examination............................................214
Lumbar Puncture..............................214
6. Pediatric Clinical Examination ..216
History.......................................................................216
Presenting Complaints/Chief
Complaints.................................................216
History of Present lllness..........2l7
History of Birth....................................220
Feeding History....................................220
Immunization........................................220
Developmental History...............220
Past History..............................................221
Family History......................................221
Social History..........................................221
Personal History..................................221
Envfronmental J·Ustory..............221
Examination.......................................................221
Gener:al Physical
Examination...........................................223
CardiovascularSystem................229
Respiratory Systcm..........................231
Abdomen....................................................233
NervousSystem ...................................235
Neonatal Examination.................238
Deve]opmental
Examination........................................... 241
The Acutely Ill Infant.................242
7. How To Present A Case?...........243
History NO. 1: Dyspnea.................243
History NO. 2: Pain Epigastrium...245
History NO. 3: Fever.........................246
8. INDEX ............................................... 248

FOREWORD
r have great pleasure in wnting a foreword for BEDSIDE TECHNIQUES: Methods
of Clinical Examination. There is no dearth of books on clinical examination but what
distinguishes this book is the stress on explaining the relevant symptoms and the correct
methods ofeliciting physical signs; this is the real justification for this book.
All the chapters io this book arc clearly written without going into unnecessary details and
deserve closestudy by undergraduatestudents, postgraduate students and medical practitioners.
Two chapters, on cardiology and neurology, deserve special praise.
Cardiology is a difficult subject to grasp but the method of clinical examination has been
clearly explained by the authors. Detailed description ofimportant cardiac conditions has been
given alongwith the approach to history and physical examination. It must be remembered,
however, that physical signs should be interpreted with the help ofrelevant investigations like
chest x-ray, ECG and where possible, echocardiography.
The chapter on clinical neurology deserves special praise for its simplicity and the confidence
which it gives to the undergraduate student not only to carry out clinical examination but also
to a!1'ive at a diagnosis. The subject of neurology has been traditionally painted as something
very difficult to grasp and only meant for specialists; this myth has• been broken in this book.
The study of clinical neurology requires a basic understanding of anatomy and physiology,
more so than any other specialty of medicine, and these facets have been clearly explained
in this book. After studying the chapter on neurology, I am sure that both undergraduate and
postgraduate student wilI find that clinical neurology is not such a bug bear as traditionally
described. The fact of the matter is that this is one speciality which most commonly allows
the correct diagnosis to be made on the basis ofclinical examination alone. One of my great
teachers used to say that the knowledge ofneurology distinguishes between a good physician
and a good quack.
1 should like to remind the student of an old dictum 'clinical medicine can be only learnt at
the bedside and not by books' but it is equally important that books be consulted to really
understand medicine. I hope the students make full use of the knowledge contained in this
book and practices the routines as described to arrive at the correct diagnosis.
I strongly recommend this book to anybody who is interested in clinical medicine. I feel that
this is a significant addition and a breakthrough in the study of clinical method·s written by
local authors. I wish and pray for the unqualified success of this book.
Dr. Abdul RaufAhmad (late)
MD; FRCP (EDIN & LOND); FCPS (PAK)
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PREFACE TO THE FIRST EDITION
The question most frequently asked of us was why we ever wanted to write about clinical
methods when there' were so many other books already in the market. This is probably the
right place to answer this question. As teachers and examiners in Medicine, we had been aware
for a long time of the unenviable position·of the brilliant medical student who has ·learnt the
method of examination, the difTcrcntial diagnosis, the significance of probabilities in their
proper order, and the prcfeITed investigations from foreign books, only to face the wrath of
the examiner who is more realistically aware of the different local disease prevalence and
diagnostic medical facilities. We have been aware too of the plight of the average medical
student for whom English remains a relatively difficult foreign language whose nuances arc
completely lost upon him and who needs to s011ggle not only with already difficult concepts
ofclinical Medicine but also bas to decipher (subtle but significant) shades ofmeaning which
arc obvious only to the native speaker ofthe English language; and a problem common to all
students - the sequence ofna1i-alion of information given in books is very different from what
is taught and expected ofthem.
When faced with these problems the sludents reso11 to 'notes' prepared by other sLudcnts and
full ofconceptual and factual cn·ors, or booklets which are little betlcr. They learn with great
diligence all that is contained within, the truth, halftruth and the gross untruth. They can go
through life without ever realizing the myths and fallacies they have imbibed. We thought ii
was time to address this problem, prompting us to write this book.
We have tried to make this book easily readable for our students. We have tried to do away
with concepts and material not relevant to local conditions and to put things in the proper
perspective, keeping in mind the constraints operating here. But we have also tried to retain
all material that the aspiring postgraduate might need. We have included a large number of
line drawings to illustrate concepts; what they lack in artistic quality we hope they make up in
content and clarity. and should make learning relatively easier.
The initial interview with the patient and the results {history taking and presentation) is usually
a particularly weak skill with our students and we have attempted lo address this problem.
We already have a publication which lists relevant questions to be asked from the patient
according to the main presenting feature and a synopsis ofdifferential diagnosis in tabulated
forms (Aids to Diagnostic Process); this would be an excellent companion book lo strengthen
what we calI "The Art ofRelevance".
There is a section on Pediatrics, not found in many current books. We think this is very timely
considering that Pediatrics will soon be a separate subject in the final professional MBBS
examination.
Departing from the usual format, we do not have sections on X-rays and ECG interpretation.
Students consult the e sections infrequently and ve1y selectively, usually relying on the
ward instructions. We have also not included examination of ENT, Eye and Gyncacology as
examination in these specialties too is usually learnt from single subject texts. This has helped
in cutting the size and price, and improving 'portability' ofthis book.
During the whole process ofwriting ofthis book we have relied on feedback from our students
and young residentstaffand we should like to continue this process so that subsequent editions
can be responsive ofreader preferences. We would appreciate any comment or suggestion that
lhc reader might make.
Multan 1 995
Muhammad lnayatullah MRCP (UK)
ShabbirAhmad Nasir FRCPE

PREFACE TO THE FOURTH EDITION
Art ofhistory taking and methods ofphysical examination don't change frequently but style of
presentation, composing, printing, illustrations and photographs can be modified to improve
the readability, understanding, interpretation and reproducibility ofthe contents. This edition
is a new look book with significant improvement in all categories of contents and printing
quality. Authors hope that this new look of "Bedside Techniques" will be of great help in
learning ofclinical ski]Is for current and future medical graduates.
Multan 2013
Muhammad lnayatullah FRCP (LONDON)
ShabbirAhmad Nasir FRCPE

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ACKNOWLEDGEMENTS
Writing a book is arduous. It would be almost impossible ifevery author didn't have a circle of
friends and colleagues who support and encourage him. Many books would remain unwritten
but for these individuals and acknowlectging their help is one of the more pleasant tasks of
writing books.
Dr. Durr-e-Sabih. Our most ruthless critic, and self-appointed guardian ofquality (readability),
who went over each line asking for itsjustification, any more effort on his parl and we would
have to give him credit as another author.
Dr. Tmran Iqbal. For reviewing the chapter on Pecliatircs.
Drs. Altaf Baqir Naqvi, Muhammad Bilal Ahsan and Muhammad Javed Rana. Registrars
(Naqvi is a senior registrar now) who have been involved in proof processing and sharing our
burden ofthe ward while we were busy with our writing.
Dr. Ra:fiquc - ur • Rehman. For arranging access to a laser printer where lhc final manuscript
was printed.
Mohammed Wamiq. Ever cheerful and full ofenergy, who has drawn all the illustrations.
Dr. Zahida Sabih. For logistic support.
Mr. Zain-ul-Abedin Iqbal, Director Paramount Publishing Enterprise for his valuable
suggestions in pictographic work of this book.
Mr. Dilshad Alam graphic designer, Paramount Publishing Enterprise for taking all the trouble
to bring the book in current shape.

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INTRODUCTION
Remember:
I hear and I forget
I see and I remember
I do and I understand
The mastery of the art of clinical
examination separates the good from
the mediocre physician. This is the basic
foundationon which thewholestructure
of medical diagnosis and management
rests. With a proper clinical examination
you arc almost within reach of the
correct diagnosis. The abundance of
Hi-tech investigations now available
might suggest to some that listening to
the patient and examining him with
care might not be very important, that
laboratory tests can substitute and
improve the knowledge gajned by the
history and examination, but this is
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far from the truth. Laboratory tests are
just data, not knowledge and undirected
investigations without proper
understanding of the patient's problem
usually yield useless information which
does nothing to help the patient. This
doesn't mean that investigations should
not be used, just that the decision to
undertake any test should be made
after a thorough understandjng of the
patient's problem and presentation. This
can only be achieved by a good history
and clinical examination.
The diagnostic process has three parts:
1 . History taking
2. Physical examination
3. Investigations

Chapter
1 <HISTORY TAKING
AND PHYSICAL
EXAMINATION
This is an interview with the patient
aimed at understanding the nature of
his illness. It can be defined as to know
about the patient's illness as he knows.
The process of history taking cannot be
restricted to a predefined pattern and has
to be modified according to the patient's
symptoms, attitude, age and level of
literacy. Following guidelines are helpful
in learning the art of history taking.
GUIDELINES FOR HISTORY
TAKING
+ Your approach to the patient should
be sympathetic, gentle, friendly and
confident but not frivolous,sarcastic
or belittling.
+ Introduce yours'?lf to the patient
first.
+ Try to communicate in the language
which the patien t can fully
understand.
+ Be courteous; in the hospital,
don't interrupt patient's personal
activities like eating etc. You should,
either wait for the patient to finish
or come some other time.
+ Allow the patient to give his own
account of current i1lness ,md then
ask questions about aspects that
remain deficient.
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First listen to the patient,thenask
necessary questions to complete
the history, and then write.
+ lf interniption is necessary, it should
be timed and planned depending
upon patient's personality.
+ Try to avoid asking leading
questions, ie, a question that can be
answered in 'yes' or 'no', eg, "have you
got pain in the chest or diarrhea"?
Instead, ask "have you got any pain
anywhere? How are your bowels'?
+ Encourage the patient to give details
of his symptoms and discourage
the use of pseudo medical terms
like 'rheumatism' 'acidity' etc. Don't
accept a diagnosis except if it has
been made by somcbocly competent
and has been based on definite
external tests as required; otherwise
ask detailsof theillnessas it occurred.
For example, somebody being told
to be a case of peptic ulcer' without
barium meal x-rays or gastroscopy is
not acceptable.
+ Avoid writing when the patient is
talking. This will give an impression
as if you are not attentive. Brief
notes can be scribbled if necessary.
Write down the history soon after
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CH I HISTORY TAKING AND PHYSICAL EXAMINATION
the interview is over and before
physical examination, so that you
don't forget the details.
+ Record the h�story in the pattern
described below. Patient's narration
doesn't follow that pattern.
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HISTORY RECORD
Write down the history under the
following headings:
1 . Name, age, sex, marital status,
occupation, address
2. Presenting complaints
3. History of present illness
4. Systemic inquiry
5. Past history
6. Menstrual history
7. Treatment history
8. Family history
9. Personal and social history
1 0. Occupational history
Name
This is the identity of the patient.
Record the father's or husbands name
as well in order to differentiate between
individuals with the same name.
Age
Some patients are not sure about their
age. An approximate age can be assessed
by the look of the patient. Information
like age at the time of marriage and age
of eldest child also can help.
Some diseases are more common in
certain age groups, eg, communicable
diseases like polio, chicken pox, measles
etc. are common in childhood while
malignancies, ischemic heart disease,
strokes are more common in older age
group.
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Sex
Apart from identification value and
specific diseases of genital organs,
certain disorders are more common in
one particular sex, eg, ischemic heart
disease is more common in males
while systemic lupus erythematosis
and primary biliary cirrhosis are more
common in females.
Occupation
It not only gives clue about patient's
socio-economic and educational status
but also tells about possible risk to his
health. It is further discussed under
occupational history.
Address
Complete postal address is vital for
future communication. In addition,
some problems like iodine deficiency,
parasitic infestations are more prevalent
in certain regions; knowledge of patient's
address may help in the diagnosis.
Presenting Complaints
These are the symptoms wh1ch made
the patient to come to the doctor. Record
them in chronological order, ie, write
the symptom which developed first at
the top followed by other complaints in
sequence of occurrence. Enter duration
of each complaint in front of it. For
exa1!1ple:
Pain epigastrium:
Vomiting:
1_2 days
10 Q.ays
Loose motions: 7 days
If a symptom has been occurring again
and again, and is present this time aswell,
include this info!mation in presenting
complaint. For example:
Recurrent pain
left lumbar region 6 months

.. or .
Recurrent bouts of cough: 2 years
Avoid writing m1n1 history, ie,
description of . symptoms under
this heading. If patient had certain
symptoms before presenting co;;;_
plaints but this time he has not come for
those symptoms, record them under the
past history.
History of Present Illness
Describe the presenting complaints in
detail one by one; in the sequence they
developed. Relevant questions to be
askedaboutvarioussymptomsare learnt
only with experience and increasing
knowledge of Medicine. A list of such
questions about important symptoms is
given on page 6:
Describe each presenting
complaint in detail at one
place and follow sequence of
occurrence of complaints.
If ,symptoms have been occurring
in bouts, describe the latest episode
in detail and then record duration
frequency and progress of these episode�
from the beginning. Record the history
in patient's words and don't substitute
medical terms for patient's description,
eg, paroxysmal nocturnal dyspnea for
breathlessness during the night and
angina for chest pain on exertion
Systemic Inquiry
The patient generally tends to tell
only those symptoms which he thinks
are important and need immediate
attention of the doctor. Either he ignores
other symptoms, considering them
Significance of various questions has been
discussed in our other book "Aids to Differential
Diagnosis".
BEDSIDE TECHNIQUES
unimportant/unrelated to present
illness or he might even forget some
of the less severe symptoms. In order to
make sure that no aspect of the patient's
illness is missed, it is recommended that
you should ask about all the cardinal
symptoms of each system as a routine
under the heading of systemic inquiry.
Some symptoms occur due to disease of
more than one system; inquire about such
symptoms only once. Similarly, don't
repeat questions about those symptoms
which already have been described
under the history of present illness. If a
symptom is present, find .out its details as
you did in history of present illness. A list
of common symptoms due to diseases of
various systems is given below.
Quickly ask about cardinal
symptoms of diseases of each
system.
·General
Appetite, weight · gain or weight loss,
sleep, energy.
Cardiovascular System
Breathlessness, palpitation, chest pain,
edema feet.
Respiratory System
Cough, sputum, hemoptysis, breath
lessness, wheezing, chest pain.
Alimentary System
Nausea, vomiting, abdominal pain,
heartburn, dysphagia, diarrhea,
· constipation, hematemesis melena
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jaundice.
Urinary System
Pain in the flanks, dysuria, hematuria,
frequency of micturition, polyuria,

oliguria, nocturia, passage of gravel in
the urine, nausea, vomiting.
Nervous System
Weakness, numbness, tingling,headache,
vomiting, giddiness, blackouts, . fits,
visual loss, diplopia.
Skin
Rash, itch, colored spots.
Locomotor System
Joint pain, stiffness, swelling, restriction
of movements.
.Endocrine
Polyuria, polyphagia, polydypsia, .heat
or cold intolerance, weight gain or loss,
sweating, palpitation.
Information from Another Person
In certain situations patient himself
cannot give the details of history. Seek
the information from another person,
particularly an eye witness. These
situations include:
+ Childhood.
+ Senility or mental retardation.
+ Unconscious/aphasic patient.
+ Convulsions with loss
consciousness.
Past History
Inquire about the following:
of
+ Nature of delivery (spontaneous,
assisted or Cesarean section; at home
or in hospital). It is more relevant in
children.
+ Congenital anomalies.
+ Communicable diseases in childhood.
+ Any significant illness (ask
description of illness if diagnosis is
not known).
..
+ History of admission to hospital,
accident or operation; ask more
details if the answer is yes.
+ Any chronic illness like
hypertension, diabetes mellitus,
ischemic heart disease, arthritis,
tuberculosis. If someone has one of
these illnesses, ask how and when it
was diagnosed, what treatment he
has been taking and how effectively
it has been controlled.
+ Residence or travel abroad. It is
becoming more relevant due to
frequent travel and. emergence of
diseases like AIDS.
Menstrual History
Note down the following:
+ Age of menarche (onset of
menstruation).
+ Duration of each period.
+ Length of cycle (from the pt day
of one period to the pt day of next
period).
+ Regularity of cycle.
+ Any pain associated with periods:
site, duration, relationship to the
onset of periods.
+ Any intermenstrual or postcoital ·
bleeding.
+ Menopause; age, pos_tmenopausal
bleeding or discharge.
Treatment History
Patients usually don't remembyr names
of drugs. Ask about any left over drugs,
labels or prescription. Note down
names of drugs, dosage and dµration of
therapy. Also ask about effect of these
drugs on patient's illness. If patient has
a prescription, find out whether he is
taking all the drugs in the prescribed
doses. If patient was not taking

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drugs regularly, find. out the cause of
non-compliance.
+ Knowledge of 'drugs taken might
give a clue to the ·nature of patient's
past or even existing disease.
+ Side effects of drugs are sometimes
responsible for patient's symptoms.
+ Some patients are sensitive to drugs
like sulfonamides, penicillin etc. and
this information helps to avoid any
catastrophes.
+ It helps to avoid any possible drug
interaction with newly prescribed
drugs, eg, anticoagulant may interact
with oral contraceptives wb,ich
patient is already taking.
Family History
Inquire about health of parents,
siblings (brother and sister) and
children, and ask questions about
individual member. Find out whether
any one of them is suffering from a
similar illness or a chronic illness like
hypertension, diabetes mellitus,
ischemic heart disease, asthma,
arthritis or tuberculosis? If any one of
them is dead, ask about possible cause of
death. If there is suspicion of inherited
disorder, ask about health of uncles and
aunts as well.
Personal and Social History
Seek the following information:
+ Patient's economic status. It is
important to decide how much
patient will be able to afford the cost
of investigations and treatment.
+ Nature of family relations.
+ Any habit or addiction, now or in the
past like smoking, drug dependence,
alcohol intake.
BEDSIDE TECHNIQUES
+ Any special worries, sleep
disturbance.
+ Dietary details if there is doubt of
n utritional abnormality.
+ Horne surroundings.
Occupational History
Seek the following information:
+ Exact nature of the present job.
+ Details of jobs in the past.
+ Any possibility of exposure to
chemicals or radiations? If yes, what
is their nature and quantity?
ROUTINE QUESTIONS ABOUT
CARDINAL SYMPTOMS
(Significance of various symptoms, signs
and investigations has been discussed
in our book "Aids to Differential
Diagnosis". It will be worth to look at.)
Pain
Site of Pain
Ask the patient to indicate where exactly
he feels the pain. Pain of duodenal ulcer
is in the epigastrium, pain of ischemic
heart disease is across the sternum and
not over the precordium while pain of
reflux esophagitis is along the sternum.
Intensity
Although the threshold of pain varies in
different people, make a rough estimate
of intensity. Pain can be mild, moderate
or severe. Pain which keeps the. patient
awake at night, or makes him toss in
the bed, is severe. Pains of myocardial
ischemia, pancreatitis, and colicky pains
are very severe.
Radiation
It means the pain spreads to some other
site while maintaining its continuity

withthemainsite,eg,painofcholecystitis
radiates from right hypochoridrium
along right costal ,margin to the back.
Similarly, pain , bf cardiac ischemia
radiates to the left arm and jaw.
Shift of Pain
It means, at first pain occurs at one site,
is relieved from there and then is felt
at another site. For example, pain of
appendicitisstarts around the umbilicus
and then moves to right iliac fossa due to
involvement of parietal peritoneum.
Referred Pain
It means pain is felt at a remote site
away from the main site due to common
nerve supply, eg, pain of cholecystitis is
felt at the tip of right shoulder.
Duration
Estimating duration of pain without
actual measurement is usually
inaccurate, but it is at times helpful in
making a diagnosis, eg, pain of angina
usually lasts for less than 30 minutes
while that of myocardial infarction lasts
for more than 30 minutes. Similarly,
persistent chest pain is less likely to be
due to ischemic heart disease.
Character
Following terms are commonly used to
describe the character of pain. Different
patients cari use different terms to
describe the same pain.
1 . Heaviness
2. Burning
3. Aching
4. Stabbing or cutting
5. Throbbing
6. Jolt like
7. Dull
8. Gripping
9. Pricking
1 0. Colicky
In colic periods of sudden severe pain
alternate with, either pain free intervals
(intestinal colic) or pain of lesser
intensity (ureteric colic).
Frequency and Periodicity ofPain
Ask the patient about du.ration of
pain free intervals and whether this is
increasing or decreasing.
Periodicity means patient gets bouts
of pain for few weeks and then becomes
completely symptom free without
treatment for few weeks. This cycle is
repeated again. This occurs in duodenal
ulcer.
Special Times of Occurrence
Pain of duodenal ulcer may waken the
patient after midnight, but it is never
present at usual hours of rising. Pain of
sinusitis is maximum few hours after
rising. Headache of migraine may occur
during menses.
Aggravating Factors
Ask the patient if any particular factor
aggravates the pain. Movements worsen
the pain of joint and muscle disease.Pain
of angina is precipitated by exertion.
Pain of peptic ulcer may be worse after
tea or spicy food. Pleuritic pain is worse
on deep breathing and coughing,
Relieving Factors
Pain of angina is relieved by rest and
sublingual nitrates. Pain of duodenal
ulcer is relieved by food and antacids.
Associated Phenomenon
Depending upon underlying disease

..
other symptoms may. be present, like
vomiting in abdominal pain due to
cholecystitis and "headache due to
meningitis, palpitation and sweating
in chest pain of ischemic heart disease,
hematuria in ureteric colic, distension·or
abdomen and constipation in intestinal
colic due to intestinal obstruction.
Fever
It means rise in the body temperature**
above upper limit of normal. Average
normal body temperature is 98.4'F (37°
C),
range is 97 - 99'F (36.6 - 37.2'C). There is a
variation of about one degree Fahrenheit
between morning and evening (diurnal
variation), being less in the morning.
Fever is a common symptom. Ask the
followingquestions from all the patients
presenting with fever.
Mode of Onset
Fever due to acute infections (eg,
malaria, pneumonia) is of acute onset
while fever due to chronic infections
(eg, tuberculosis) and malignancies is of
gradual onset.
Rigors or Chills
These indicate sudden rise in the body
temperature. Malaria is a common
cause but these can occur in any acute
infection like pneumonia, urinary tract
infection.
Grade of Fever
Fever of acute infections is of high
grade while fever of chronic infections
is usually of low grade.***
* Celsius (centigrade) scale is commonly used all
over the world, but we in Pakistan are more familiar
with the Fahrenheit scale. Formula to convert one
scale into the other js Celsius ~ Fahrenheit - 32 X 5/g
.., • There is no precise definition of grades of fever.
BEDSIDE TECHNIQUES
Pattern of Fever
Continuous fever. Temperature does
not touch the baseline and variation
between maximum and m1mmum
temperature in a day is of less than re
(lSF). Fever in typhoid is continuous.
Remittent fever. Temperature does not
touch the baseline and daily variation is
more than 2'C (3'F). Fever due to most of
infections is remittent.
Intermittent fever. Fever is present
for several hours followed by fever free
interval. In tuberculosis usually there
is evening rise of temperature followed
by night sweats. In malaria fever is
typically intermittent. Following are the
subtypes of intermittent fever.
Quotidian fever. Bout of fever occurs
daily for few hours.
Tertian fever. Fever occurs on alternate
days.
Quartan fever. Fever occurs after an
interval of two days.
Relapsingfever.Fever occursforseveral
days followed by fever free interval of
similar duration; this cycle is repeated.
Relapsing fever due to Hodgkin's disease
is called Pel Ebstein fever.
Associated Symptoms
Headache and vomiting are ·nonspecific
symptoms and accompany fever of any
etiology, but if persistent, meningitis
must be excluded. Certain syµiptoms
point towards possible site of infection
in a feverish patient. These are:
+ Ear discharge.
Usually fever of more than I02'F (39'C) is considered
as high grade and fever of less than JOJ'F (38.:i'C) is
considered as low grade. If temperature rises above
JOTF (-11.6'C) it is callecl hypcrpyrexia; if it falls below
95'f (35'C) it is called hypothermia.

Site
Radiation
Character
Severity
Perie·
dicity
Special
timeof
occurr-
ence
Aggrava·
ting
factors
Relieving
factors
Associ -
ated
pheno-
mena
Signs
DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN
Peptic Cholccy-stitis Pancrea- Rena1 Uretcriccolic Appcncli- Worm IntestinaI Hepatitis
ulcer titis pain citis infestation obstruc•
epigas- right hypo- epigas- lumbar
trium chon-drium trium region
localized back,right back localized
shoulder
gnawing colicky gnawing dull
oraching or cutting
mild to moderate to severe mild to
severe severe moderate
present absent absent absent
after none none none
midnight
empty fatty meal none move-
stomach ments
foodand none bending none
antacids forwards
vomiting, vomiting,fever vomiting urinary
hemate- symptoms
mesis
melena
tender- tenderness mild tenderness
nessin in right tenderness in lumbar
epigast- hypochon- inepigas· region,
rium drium, trium, kidney
Murphy'ssign hypoten· maybe
is positive sion palpable
lumbar region umbilicus,
right iliac
fossa
groin localized
colicky
moderate to mildto
severe moderate
absent absent
none none
move-ments none
none none
vomiting, vomiting,
urinary fever
symptoms
kidney may tender-
bepalpable ness, mass
if there is in right
hydronephrosis iliacfossa
upper
abdomen
whole
abdomen
achingor
colicky
mild to
moderate
absent
none'
none
none
anemia
tion
generalized right hypo
chondrium
colicky
moderateto
severe
absent
none
none
none
vomiting,
distension
of abdomen,
obstipation
borborygmi
audible
aching
mild to
moderate
absent
none
none
none
anorexia,
nausea,
vomiting
jaundice,
tender
hepato
megaly
I

..
+ Sore throat.
+ Cough, expectoration (respiratory
infection).
+ Pain right hypochondrium
(cholecystitis, amebic liver abscess).
+ Diarrhea with blood and mucus
(dysentery).
+ Pain in flank (pyelonephritis).
+ Dysuria, burning micturition
(urinary tract infection).
+ Night sweats (tuberculosis).
Weight Loss
+ If previous weight is known,
weigh the patient to find· the
difference; otherwise ask the patient
approximately how much he has
lost.
+ How is appetite: weight loss may be
associated with poor or good appetite.
+ If appetite is decreased, ask about
fever, night sweats, cough and
expectoration. (Weight loss with
poor appetite may be due to chronic
infection or malignancy.)
+- If appetite is normal or increased,
ask about polyuria, polydypsia,
palpitation, heat intolerance or
chronic diarrhea. (Weight loss
with good appetite may be due to
diabetes mellitus, thyrotoxicosis or
malabsorption.)
Mass
It may occur anywhere in the body. Ask
about:
+ Duration.
+ Site.
+ Recent change in size.
+ Pain.
+ Fever.
BEDSIDE TECHNIQUES
+ Pressure symptoms (eg, dyspnea or
dysphagia if mass is in the neck).
Edema
+ Site - it may be generalized ('eg,
nephrotic syndrome) or localized
(eg, CCF):
+ Where did it start first - around the
eyes (renal disease) or feet (CCF)?
+ Ask about breathlessness (CCF);
anorexia, vomiting, oliguria (renal
failure); indigestion, diarrhea
(malabsorption); distension of
abdomen (cirrhosis.of liver).
Dyspnea (Breathlessness)
It is of two types: exertional dyspnea
(dyspnea precipitated or made worse by
exertion) and dyspnea at rest (dyspnea
which comes in attacks without any
relation to exertion).
Exertional Dyspnea
+ Duration.
+ How much exertion precipitates
dyspnea, eg, does it come on
climbing stairs, running or walking
at a normal pace, and how much
distance can the patient walk
without becoming dyspneic?
+ Has it been progressive, ie, has the
amount of exertion • precipitating
dyspnea been decreasing since the
dyspnea started?
+ History ofsudden wakening at night
due to breathlessness (paroxysmal
nocturnal dyspnea).
+ History of such exacerbation that
dyspnea is present at rest or becomes
worse on lying flat (orthopnea).
+ Associated symptoms (cough,
sputum, palpitation, sweating, chest
pain).

+ Past history of chest pain,
hypertension or fever with joint
pain (rheumati� fever).
Dyspnea at Rest·(Unrelated to
Exertion)
Dyspnea occurs in episodes due to
bronchospasm (bronchial asthma).
+ Age of onset.
+ Wheeze (whistling sound).
+ Frequency, severity and duration of
attacks.
+ Change in frequency, severity
and duration of attacks since first
episode.
-+ History of skin or nasal allergy.
+ Family history of similar illness or
allergy.
+ Does patient require regular
treatmentto remain symptom free?
Palpitat
ion
It means the awareness of heart beat.
Find out following information.
+ Does it come in attacks at rest
(paroxysmal tachycardia) or occurs
on exertion?
+ Duration of an attack.
+ Does it start and terminate suddenly
or gradually?
+ Associated symptoms
(breathlessness, chest pain, sweating,
loss of weight despite good appetite,
heat intolerance).
1
Cough
+ Duration.
+ Frequency and severity.
+ Is it more at night or during the day?
+ Is it dry or productive?
..
+ What is the quantity, color and smell
of the sputum?
+ Is sputum more early in the
morning?
+ History of hemoptysis (blood in
sputum). Is blood mixed with
sputum or.pure (frank hemoptysis)?
What is frequency of hemoptysis
and quantity of blood?
Vomiting
+ Duration.
+ Frequency.
+ Relation with food intake.
+ Any special timing.
+ Loss of weight, if vomiting is long
standing.
+ Quantity, color, smell and contents
of vomitus.
+ Bloodinthevomitus(hematemesis);
if yes its color, quantity and
frequency, and associated melena
(black colored, foul smelling stools).
+ Other symptoms like pain abdomen,
constipation and distension of
abdomen (intestinal obstruction);
anorexia (carcinoma stomach,
renal failure) oliguria (renal
failure); headache (migraine, raised
intracranial pressure, meningitis).
Diarrhea
+ Duration.
+ Frequency of stools.
+ Quantityofstools-smallorbulkyand
difficult to flush (malabsorption).
+ Consistency (watery stools with
specks of fecal matter are typical
of cholera and are called rice water
stools).
+ Blood or mucus in the stool.

T
I ..
+ Tenesmus (s�nse of incomplete
evacuation).
+ If diarrhea, 'is acute, any relation
with food ·intake and history of
diarrhea in other individuals who
took the same food (food poiso-rifog);
if so, interval between food intake
and onset of diarrhea.
+ Does it occur at night (nocturnal
diarrhea is always due to organic
disease of the gut)?
+ Other symptoms (fever, abdominal
pain, vomiting, weight loss).
Constipation
+ Usual bowel habits (how many
stools per week).
+ Duration (recent change in bowel
habits is important).
+ Blood in feces.
+ History of alternating diarrhea.
+ Drug history.
+ Change in eating habits.
+ Other symptoms (abdominal pain,
distension and vomiting, loss of
weight).
Dysphagia
+ Duration.
+ Is it more to solids or liquids?
+ Is it progressive?
+ Is there a feeling of food sticking
somewhere? What site?
+ Is swallowing painful?
+ Loss of weight.
+ Vomiting; does vomitus contain food
eaten 48-72 hours earlier (achalasia)?
+ Past history of retrosternal burning
(reflux esophagitis).
BEDSIDE TECHNIQUES
Jaundice
+ Pain right hypochondrium
(moderate, localized and continuous
pain may be due to hepatitis;
recurrent, severe, colicky pam
radiating to the back is due to
gallstones).
+ Loss of appetite.
+ Distaste for smoking, if patient is
smoker (hepatitis).
+ Color of stools and urine.
+ Itching (cholestasis).
+ Loss of weight (malignancy).
+ Past history of injections, blood
transfusion (hepatitis B or C).
+ Contact with jaundiced patient
(hepatitis A or E).
+ Family history of jaundice
(inherited disorders).
Polyuria
+ Duration.
+ It should be differentiated from
frequencyofmicturition.Inpolyuria
quantity of urine passed each time is
large while in frequency it is small.
+ Excessive thirst (polydypsia).
+ Appetite: normal, increased or
decreased.
+ History of diuretic intake.
+ Is it more at night (nocturia)?
Hematuria
+ Duration.
+ Exact color of urine.
+ Any difference in the color of urine
in the beginning, in the middle or at
the end of micturition?
+ Associated symptoms (fever,

burning mictur.ition; pain . in the
hypogastrium, lumbar region or loin
to groin).
Fits (Convulsions)
+ What was the age at the time of the
first attack?
+ Gather the following information
about an attack from the patient
and an eye witness:
Aura (any special feeling or
symptoms before the fit).
Loss of consciousness.
Rigidity.
Tonic, clonic contractions.
• Are the fits generalized or
localized?
Tongue bite, urinary/fecal
incontinence.
Fall, trauma.
Duration of attack.
After symptoms, eg, sleep,
headache, paralysis.
Do the attacks occur during sleep
or not?
+ What has been the shortest and the
longest interval between the attacks?
+ History of headache, vomiting,
sensory or motor symptoms or fever
(febrilefitsarecommon in children).
+ Past history of ear discharge, head
injury or birth trauma.
Weakness or Paralysis
+ Which part is involved: one limb
(monoplegia), both limbs on one
side (hemiplegia) or both legs
(paraplegia)?
+ Is weakness complete (paralysis) or
partial (pareses)?
+ Onset: sudden or gradual.
+ Is it static or progressive?
+ Premonitory symptoms
headache, vomiting.
+ Loss of consciousness.
+ Fits.
+ Is speech affected?
..
like
+ Sensory symptoms (numbness,
tingling, pain) or visual symptoms.
+ History of hypertension, ischemic
heart disease, diabetes mellitus,
valvular heart disease or smoking.
+ Past history of similar episode; if yes
what was the outcome.
+ Family history of vascular disease.
Headache
+ Site (psychogenic headache is
over the vertex while headache
due to organic disease is frontal or
occipital).
+ Severity.
+ Duration.
+ Continuous or intermittent
(duration of each episode and
frequency of episodes).
+ Character.
+ Special time of occurrence (cluster
headache usually occurs at night
while headache of sinusitis is
maximum few hours after sunrise).
+ Aggravating and relieving• factors.
Attack of migraine may be
precipitated by menses and certain
foods like cheese. Headache of
sinusitis is worse on stooping.
+ Associated phenomena like
vomiting, visual halos, rhinorrhea.
+ Insomnia.

11111
+ Any cause for anxiety or depression.
+ Effect of analgesics (psychogenic
'
headache is not relieved by
analgesics although these are taken
very frequently).
Joint Pain
+ Age of onset.
+ Which joint was involved first?
+ What was the sequence of
involvement of other joints?
+ Did the pain in the previously
involved joint persist or disappear
when other joints were affected?
+ Swelling of joints.
+ Relation of pain with movements of
joints.
+ Morning stiffness.
+ Past history of trauma to the joints.
+ Any systemic symptoms?
+ History of urinary, bowel or eye
problems.
PHYSICAL EXAMINATION
The examination should begin the
moment you see the patient. Observe the
general look of the patient, and his gait
if he walks in. Make an assessmentabout
his behavior, mental state and level of
education during history taking.
Practice a sequence of exami
nation and then adhere to this
sequence.
A routine of examination should be
developed so that no important step
is omitted. Sequence of examination
should be such that one can perform
speedy but thorough examination
with minimum necessary disturbance
to the patient. It should be regional
BEDSIDE TECHNIQUES
rather than systemic. This routine can
vary with the individual doctor, and
should be modified according to the
circumstances and patient's condition. It
will be different in a patient who walks
into a clinic than in an unconscious
patient admitted to a hospital. In a
seriously ill patient, examination should
be restricted to a minimum necessary to
make a provisional diagnosis. Initiation
of treatment should not be delayed
just for the sake of completion of
routine examination. A chaperone
(female attendant, nurse or female
student) should be present when a male
doctor/student is examining a female
patient.
WRITING OUT THE
EXAMINATION
Whiletheexamination is doneonregional
basis, the findings are recorded under
systems with headings. This needs a little
practice at first, but then proficiency
develops very quickly. In this book
methods are described under systemic
headings and at the end a regional
sequence of examination is given.
GENERAL PHYSICAL
EXAMINATION
The following scheme is useful for a
speedy and thorough GPE (General
Physical Examination). A physical sign
may be seen at more than one sites, but
this should be recorded and described at
one place.
A sequence ofrecording general physical
examination is given at the end of this
chapter(page 32).
General Appearance
Make a quick assessment of degree of
patient's illness whether he looks well,
mildly ill or severely ill.

Posture and Attitude
The patient's posture and attitude
sometimes give iitformation about his
illness. For example:
+ A patient of severe heart fai:l-ure
prefers to sit propped up because his
dyspnea worsens on lying flat.
+ A Patient with severe airways
obstructionsits up, bending forwards
and supporting himself with his
arms, so that shoulder girdle is fixed
and he can use extra respiratory
muscles.
+ A patient of peritonitis lies still
while the patient with severe co'lic is
restless.
+ In meningitis the neck may be bent
backwards (neck retraction).
Consciousness
Notewhetherpatientlooksalert,confused
and drowsy or deeply unconscious
(assess level of unconsciousness using
Glasgow coma scale given on page 144).
Physique
Although, generally a visual impression
is made about patient's height and
weight, preferably both should be
measured and compared with tables of
ideal height and weight, particularly
if patient looks obese, undernourished,
abnormally tall or short. Dosage of
drugs is also calculated according to the
patient's weight or surface area (which is
determined using a nomogram). Regular
measurement of weight is useful to
monitor the response in patients with
edema or ascites. In unduly tall and
short patients sitting height should
be compared with arm span and total
height.
..
Normally sitting height
(height of the person while
sitting on his buttocks) is
half the total height or arm
span (measured from the tip
of middle finger of one hand
to the tip of middle finger of
other hand when arms are
fully extended).
In Marfan's syndrome and
hypogonadism arm span is
more than double the sitting
height.
In achondroplasia arms and
legs are short while trunk is
normal, so sitting height is
more than length of legs as
measured from pubis to feet.
In congenital hypopituitarism
(pituitary dwarf) total height
is less than normal, but limbs
and trunk are proportionate.
Hand
Examine nails, fingers and palm in
detail, but at first have a general look at
the hand and note the following:
Shape: Hands adopt special shape
in tetany due to carpal. spasm (see
under nervous system examination).
Short 4th metacarpal (which becomes
evident on making a fist) in a female
is seen in Turner's syndrome. Short
4th;5th metacarpal is also seen m
pseudohypoparathyroidism.
Size: Hands are large and broad in
acromegaly.
Tremor,
Discussed
grip, muscle wasting:
under nervous system
examination.

..
Common signs in hand
Nails
Pallor
Cyanosis
Koilonychia
Clubbing
Fingers
Heberden's nodes
Swelling of joints
Palm
Pallor
Swea,ting
Nails
Pallor: There is marked variation in the
color of the nails in normal individuals.
It becomes pale in anemia.
Cyanosis: It means bluish discoloration
(see page 26).
Koilonychia: Nails become thin, brittle
and concave (spoon-shaped) (fig 1.1). It
is seen in long standing iron deficiency
anemia.
Clubbing**: It consists of following
changes:
+ There is loss of angle between
nail and nail base (fig 1.2, 1.3, 1.4). It
can be assessed by 1) examining the
fingers from the side in profile 2) by
palpating the nail from distal end
towardsbase of the nail 3) by placing
a piece of paper across the nail and
nail base, normally their remain an
opening between the paper and the
* Hypcrtrnplnc ostcoartl1roparhy: Clubbing
is as,ociated with �welling ,md tenderness above
the wrist and anklr· due to �ubpcrinstcal new bone
formation. Although it can nrcur in any pathology
causing clubbing, i t is more commonly associated
with respiratory dise,1se& and is then called
pulmonary hypertn,phic ostcoarthrorathy.
BEDSIDE TECHNIQUES
proximal part of the nail which is
absent if angle is obliterated 4) by
Schamroth's sign. When two fingers
are approximated, normally there is
a space between two nails. It is absent
in clubbing; fig 1.7).
I Fig 1.1: Koilonychia (spoon-shaped nail) I
[____
�::,]
Fig 1.2: Normal angle
I Fig 1 .3: Early clubbing
I
Fig 1 .4: Late clubbing
+ Fluctuations are pr�sent at
nail base; method to elicit these
fluctuations is shown in fig 1.8.
+ Thecurvatureof thenail isincreased,
both, in transverse and longitudinal
axis, and nailbecomesconvex.Normal
people can have curved nail but angle
is normal (fig 1.5).

i-------_::_
·--------..
Fig 1 .5: Curved nail with normal angle
+ Finally, due to overall swelling,
terminal phalanx becomes bulbous
andresemblesthe endof a drumstick
(fig 1.6).
Fig 1 .6: Drumstick
+ Schamroth'ssign ispresent. (When two
fingers are approximated, normally
there is a space between two nails. It is
absent is clubbing; fig 1.7.)
A B
Fig 1 .7: Schamroth's sign: fingers held together -
space seen at point X in A (normal) is absent in B
(clubbing)
..
[i=i"i Ll:Method of eliciting fluctuations in clubbini]
Causes of clubbing
Respiratory disease
1 . Chronic suppurative conditions
(bronchiectasis, lung abscess,
empyema)
2. Carcinoma lung
3. Fibrosing alveolitis
Cardiovascular disease
1 . Cyanotic heart disease (Fallot's
tetralogy, transposition of great
arteries)
2. Infective endocarditis
Gastrointestinal tract disease
1 . Malabsorption syndrome
2. Crohn's disease
3. Ulcerative colitis
4. Primary biliary cirrhosis
Miscellaneous
1 . Familial
2. Pseudoclubbing (it is seen m
hyperparathyroidism; there is
resorption of terminal 'phalanx
which gives impression of
11 clubbing)
Splinter hemorrhages: These are
vertical hemorrhagic streaks under the
nails and are commonly seen in manual
workers (fig 1.9). These can also occur in
infective endocarditis.

..
Fig 1.9: Splinter hemorrhages
Leuco nychia: These are white patches
in nail plates often present in normal
persons and are also sometimes seen in
hypoalbuminemia.
Pitting of nails: There are a large
number of small pits in the nails (fig
1.10). This occurs in psoriasis.
II
-
BEDSIDE TECHNIQUES
A B
Fig 1 .11 : Nodes in the fingers (A) Heberden's (8)
Bouchard's
;:
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
�
::
_
1 + Anterior subluxation of the
metacarpophalangeal joints with
Fig 1.10: Pitting of nails
Fingers
Osier's nodes: These are pea size painful
swellings in the pulps of terminal
phalanges. These are seen in infective
endocarditis and are due to vasculitis.
Heberden's nodes**: These are bony
swellings on the side of terminal
interphalangeal JOmts, and are
osteophytes seen in osteoarthritis (fig
l.llA, 1.12).
Joint swelling/deformity: In
rheumatoid arthritis proximal
interphalangeal joints are swollen and
fingersbecomespindleshaped(fig1.13).
In long standing rheumatoid arthritis
following deformities can occur.
•Boucharrl's 110c/e.,'.ThesearesirnilartoJ-leberdcn's
nodes and occur at proximal intcrphalangeal joints
(fig l.llB, 1.12}
ulnar deviation (fig 1.14B).
+ Swan neck deformity
(hyperextension at proximal
interphalangeal joint and fixed
flexion at the distal interphalangeal
joint - fig 1.14A).
+ Button-hole deformity (fixed
flexion at proximal interphalangeal
joint and extension at terminal
interphalangeal joint - fig 1.14A).
+ 'Z' deformity of thumb.
Arachnodactyly: It means fingers are
thin and long, and are seen in Marfan's
syndrome.
Palm
Pallor: Color of palmar skin becomes
pale in anemia.
Palmar erythema: Redness of the
thenar and hypothenar eminences

is seen in some normal subjects. It
is also a feature of hepatic failure,
pregnancy, rhe,u'matoid arthritis and
oral contraceptive therapy.
Bouchard's
node
Fig 1.12: Osteoarthritis; Heberden's and Bouchard's
nodes
Fig 1.13: Rheumatoid arthritis; swollen proximal
iilterphalangeal joints
Button-hole deformity
A
Swan neck deformity
Fig 1.14: Rheumatoid arthritis (A) button-hole and
swan neck deformities (B) ulnar deviation
Sweating: Excessive sweating on the
palm may be idiopathic but is also
seen in anxiety (palm is cold) and
thyrotoxicosis (palm is warm).
Dupuytren's contracture: There is
thickening of the palmar fascia felt as
thickened plaque or cord between palm
and ring and little fingers. Later, flexion
contracture of the fingers, particularly
ring and little fingers may develop. It is
a feature of alcoholic cirrhosis.
Pulse
Detailed examination of pulse is
discussed under cardiovascular system.
In GPE its rate and regularity should be
noted.

Blood Pressure
You must measure the blood pressure
. . .
m every patient. Some doctors prefer
to measure it during general physical
examination while others do so at the
end of examination. It doesn't mal(�
any difference as long as measuring the
blood pressure isn't forgotten. Technique
is discussed under cardiovascular system
examination (page 43).
Face
Common physical signs which must
be looked for on the face are puffiness,
pallor of the lower conjunctiva for
anemia, yellow discoloration of the
sclera for jaundice, bluish discoloration
of the tip of the nose and ear lobules
for cyanosis, bluish discoloration of
the inner surface of the lower lip for
cyanosis, dryness, pallor and cyanosis of
dorsum of the tongue and yellowness of
the undersurface of the tongue.
Facies of Cushing syndrome,
xanthelasmas, exophthalmos, butterfly
rash, and hirsutism are comparatively
uncommon.
Common signs to be looked for
on the face
Puffiness
Pallor of the lower conjunctiva
Yellow discoloration of the
sclera
Bluish discoloration of the tip
of the nose and ear lobules
Bluish discoloration of the
inner surface of the lower lip
Dryness, pallor and cyanosis of
the dorsum of the tongue
Yellowness of undersurface of
the tongue
BEDSIDE TECHNIQUES
General appearance: There are certain
characteristic facies, eg, moonlike
face of Cushing's syndrome, masklike
(expressionless) face of Parkinsonism.
Puffiness: This is due to periorbital
edema and is seen in renal failure,
nephrotic syndrome and acute
glomerulonephritis. It may also be due
to angioedema and myxedema. In right
heart failure puffiness of the face is
uncommon and only occurs if patient
can lie flat.
Proptosis (exophthalmos): It means
protrusion of the eyeball. If eyes look
unusally prominent, inspect them from
above. Stand behind the seated patient,
draw the upper lids gently upward, and
note the relationship of the corneas to the
lower lids. If cornea is protruded beyond
the lower lid exophthalmos is present. In
Grave's disease exophthalmos is usually
bilateral, although it may be unilateral
initially. Orbital tumor is another cause
of unilateral exophthalmos. Other
eye signs of Grave's disease are lid
retraction and lid lag**.
Xanthelasmas: These are yellow
plaques on eyelids due to deposition of
lipids. These may be associated with
hyperlipidemia, but are also seen in
elderly with normal lipids.
Color of the conjunctiva: Ask the
patient to look upwards, pull the
lower eyelid downwards to expose
the conjunctiva (fig 1.15) and look for
pallor. Subconjunctival hem9rrhages
• Lid retraction: Ask the patient to look str .ii.�ht
Normally sclera above and below the c:orrw.1 is not
visible. ln thyrotoxicosis sclera above the cornea
may be visible clue to lid rctrartion while i n marked
proptosis sclera, both, above and below the corned is
visible.
Lid lag Ask the patient to look straight at your
finger and then follow it downwards. Normally both
eyeball and upper eyelid move together while in
thyrotoxicosis upper eyelid may lag behind.

are seen as bright patches on the eyeball
and occur without any cause but may be
due to trauma or bJeeding disorders.
�
11
� 1 1 1 1
.J , ll,", ,
<,
jFig 1 .15 Exposure of the lower conjunctiva for pallor I
Color of sclera: Ask the patient to look
downwards and pull the upper eyelid
upwards (fig 1.16). Normal sclera is white.
In jaundice it becomes yellow.
Fig 1 .16: Exposure of the upper sclera for jaundice
Rash: In systemic lupus erythematosis,
there is rash over the cheek and bridge
of the nose (butter fly rash).
..
· Color of skin: Bluish discoloration of
tip of the nose and ear lobules occurs in
cyanosis. Redness on the cheeks (malar
flush) may be due to mitral stenosis, but
may be seen in normal individuals too.
Hirsutism: There is excessive growth of
hair on face (:i:noustache and beard area),
limbs and trunk in a female.
Parotid glands: Swelling of parotid
glands may be due to mumps (usually
bilateral) or tumor (unilateral).
Lips: Pull the lower lip and look for
bluish discoloration of its inner surface
due to cyanosis.
Tongue: Look for dryness (which isseen
in dehydration and mouth breathers),
pallor and cyanosis on the dorsum of
the tongue.
Look for jaundice on the undersurface
of the tongue.
Look for size
is enlarged
acromegaly).
Neck
of the tongue (tongue
in amyloidosis and
Examine the neck for:
+ Thyroid.
+ Neck veins.
+ Lymph nodes.
Thyroid
It consists of two lobes lying on either
side of the trachea and connected to each
other by the isthmus. Enlargement of
the thyroid is called goiter.
Inspection
Ask the patient to extend the neck and
look for obvious swelling on either side
of the trachea or in front of it. Ask the
patient to swallow. Any swelling that
moves up with laryngeal cartilage
on deglutition (swallowing) is
'

...
enlarged thyroid. Note its size, whether
it is unilateral or bilateral, diffuse or
nodular. 1'
Palpation
It can be carried out, both, from front
and back (fig 1.17). Put both your hands
over the swelling and palpate. Ask the
patient to swallow and note various
characteristics as swelling moves under
your fingers. Note:
+ Size.
+ Diffuse, single nodule or multiple
nodules.
+ Consistency.
+ Tenderness.
Fig 1 .17: Palpation of thyroid fror:n behind
Retrosternal thyroid. Thyroid can
be partially or totally retrosternal and
in this case its lower limit cannot be
reached. When patient is asked to raise
the arms above his head, there is stridor,
face is congested and neck veins become
distended; this is called Pemberton's sign.
Auscultation
A bruit (a sound resembling murmur,
see page 64) may be audible if thyroid
BEDSIDE TECHNIQUES
is hyperfunctioning. Ask the patient to
hold his breath while auscultating for
thyroid bruit with the bell. It should
not be confused with murmur radiating
from heart, carotid bruit or venous hum
(page 65).
Neck Veins
Examination of pulsations in the jugular
veins gives a nearly accurate estimation
of the right atrial pressure (which is also
called jugular venous pressure or central
venous pressure). Examine the patient
from right side while head of the bed
is elevated about 45 degrees. Look
for venous pulsations in the internal
jugular vein along the anterior border of
the sternomastoid and measure vertical
distance from the highest point of
venous pulsations to the sternal angle. If
it is more than 3 cm it is abnormal. More
details are given on page 45.
Lymph Nodes
Lymph nodes of the neck are divided
into following groups (fig 1.18):
+ Submental (under the chin).
+ Submandibular (under the jaw).
Fig 1 .18: Lymph nodes groups in the neck

+ Pre and postauricular.
+ Occipital.
+ Lymph nodes �of posterior triangle
behind the sternomastoid.
+ Lymph nodes of anterior triangle.in
front of the sternomastoid.
Method of Palpation
Stand behind the patient, flex his neck
andpush middle andringfingers of both
hands under the chin. Move the fingers
backwards to palpate submental and
submandibular groups. Then palpate
in front and behind the auricle and
over the occiput. Move your fingers
downwards behind the sternomastoid
towards clavicle for lymph nodes of
posterior triangle. For palpation of
supraclavicular fossa, push your
fingers behind the clavicle (fig 1.19).
Finally, move the fingers upwards
between trachea and sternomastoid for
lymph nodes of anterior triangle.
Fig 1 .19: palpation of supraclavicular lymph nodes
Note the following features if lymph
nodes are palpable:
+ Site.
+
+
+
+
Size.
Number.
Consistency.
Mobility withreferencetoeachother
(matted or discrete), to overlying
skin and to underlying structures.
+ Tenderness.
+ Discharge or sinuses.
Lymph nodes are tender in acute
infection, matted together in
tuberculosis (sinuses may also be
present), discrete and of rubbery
consistency in Hodgkin's disease and
hard in consistency in metastases.
Axillary Lymph Nodes
There are six groups: anterior, posterior,
lateral, medial, central and apical.
Right Axilla
Elevate patient's arm above his head
and push fingers of the left hand up in
the axilla, palm facing patient's chest.
Bring back patient's arm alongside his
chest. Move your fingers downwards
along the chest wall. If lymph nodes are
enlarged, they will slip between your
fingers and patient's chest (fig 1.20).
Elevation of patient's arm is necessary to
reach the apex of the axilla. In this way
apical, central and medial groups are
palpated.
Fig 1.20: Palpation of right axillary lymph nodes

..
For palpation of anterior group, hold
anterior axillary fold between thumb
and fingers of your left hand. For lateral
group, place pafmar aspect of fingers of
your right hand along the medial side of
the humerus.
When a group of lymph node is
palpable, examine its drainage
area.
For posterior groups of both sides, hold
posterior axillary folds between thumb
and fingers of your corresponding hand
from behind the patient.
Left Axilla
Same process is repeated but apical,
central and medial groups are palpated
with the right hand (fig 1.21) while
lateral group is palpated with the left .
hand.
Fig 1.21 : Palpation of left axillary lymph nodes
Epitrochlear Lymph Nodes
Thesearepalpatedby the methodshown
in fig 1.22.
Fig 1 .22: Palpation of epitrochlear lymph nodes
BEDSIDE TECHNIQUES
Lymph Nodes of Groin
These are easily palpable over the
inguinal ligament, if enlarged. Isolated
enlargement of this group is less
significant compared with other groups.
Note
Lymph nodes are commonly enlarged
due to disease of the drainage area,
eg, infection or malignancy. So when
you detect an enlarged lymph node,
examine the drainage area of that
lymph node to exclude any pathology.
Examine scalp, face and oral cavity in
case of cervical lymph nodes, upper limb
in case of axillary lymph nodes and
lower limb in case of inguinal lymph
nodes.
Causes of enlarged lymph nodes
1 . Infection or malignancy in
drainage area
2. Tuberculosis
3. Lymphomas
4. Leukemias
Feet
Look for clubbing, koilonychia and
cyanosis in the feet as well. Feet are
commonly affected by ischemia due to
peripheral vascular disease; early signs
are loss of hair and shiny skin.
Edema
Look for edema over the dorsum of the
foot, behind medial malleoh,1s and over
the shin. In a bedfast patient also
check over the sacrum. Compare
two sides. Press the thumb for at least
5 seconds. If edema is present, a pit is
formed which refills gradually. In
cardiovascular conditions, edema is
more prominent in lower half of the
body. In hypoproteinemia, there is

generalized anasarca.and pitting can be
demonstrated over the upper half of the
body as well.
Causes of Edema
Pitting edema
Generalized/bilateral
A. Cardiovascular (only in the lower
half of the body)
1 . Right heart failure
2. Constrictive pericarditis
3. Pericardial effusion
4. Inferior vena cava obstruction
B. Renal (generalized, but more on
the face)
1 . Renal failure
2. Nephrotic syndrome
C. Hypoproteinemia; other
than nephrotic syndrome
(generalized)
1 . Cirrhosis of liver (decreased
synthesis of albumin)
2. Malnutrition
3. Malabsorption
Localized (only in the affected part)
1 . Venous obstruction
2. Immobile, bedridden patient, eg,
paralysis
3. Inflammation (eg, cellulitis)
Non-pitting edema*
1 . Lymphatic obstruction
a. Filariasis
b. Milroy's syndrome
c. Surgical removal/irradiation of
lymph nodes
2. Angioedema
3. Myxedema
• J part of the body looks swollen (veins, tendons
and bones are obscured) but there is no pitting on
pressure. It should be differentiated from obesity in
which skin is normal and foot (hand in case of upper
limb) is spared while in non-pitting edema skin is
thickened and foot (or hand ) is swollen too.
..
State of Hydration
In dehydration (loss of fluid from the
body):
+ Eyes are sunken.
+ There is dryness of tongue.
+ Skin elasticity is decreased. (It is
demonstrated by pinching a fold of
skin between thumb and fingers; it
will subside abnormally slowly. In
elderly, this sign is less reliable.)
+ Pulse is rapid and blood pressure
is low.
+ Urine output is decreased.
Respiratory Rate
It should be counted for full minute
counting abdominothoracic movements.
Normal rate is 14 - 16/minute.
Temperature
Thermometer can be placed at various
sites for recording the body temperature,
eg, under the tongue, in the axilla, groin
or rectum. Mouth or axilla is the usual
sites. The rectal temperature is l.O'F
higher than the oral temperature which
in turn is l.O'F higher than the axillary
temperature. Rectal readings are more
reliable than oral or axillary readings.
Normal average oral temperature is
98.4°
F (98'F - 99'F) with a variation of
l.O'F between morning and evening
(diurnal variation).
Patient should not have taken
hot or cold drink immediately
before recording oral temperature.
Thermometer should be shaken well
below 98.4'F and left in place for
1/2- minutes (a little longer than the
manufacturer instructions).

II
.. Pallor
Anemia (reduced hemoglobin
concentration) is the most
common cause of pallor.
Vasoconstriction (as a result -of
shock, heart failure and exposure
to coldor Raynaud's phenomenon)
and hypopituitarism are other
causes. It should be looked for at
following sites:
Nails
Palmar skin
Lower conjunctiva
Dorsum of the tongue
Vasodilatation may deceptively
produce pink color in the presence
of anemia.
Cyanosis•
If the concentration of reduced
hemoglobin in blood rises above 5
gm%, a bluish tinge is seen in the
skin and mucous membrane; this
is called cyanosis. Sites to look for
cyanosis are:
Nails
Tip of the nose
Ear lobule
Inner surface of the lip
Tongue
• Bluish discoloration also occurs due to
sulfhemoglobin and methemoglobin which
arc abnormal pign1ents formed as a resul t
of exposure to certain clrugs or toxins. The
patient is not breathless. Oxygen saturation
of hemoglobin is normal. Diagnosis is made
by spectroscopic examination of blood.
BEDSIDE TECHNIQUES
·I Peripheral cyatiosis
If only nails, nose and:ear lobules
are cyanosed while the color of
the lips and tongue is normal, it is
called peripheral cyanosis. It is due
to eith�r reduced blood supply or
I
defective venous drainage. The
hands are usually cold in this
condition.
Causes
- 1 . Exposure to cold
2. Severe hypotension
3. Raynaud's.phenomenon
4. Venous obstruction
Central cyanosis
If lipsandtonguearealsocyanosed,.
it is called central cyanosis. It
may be due to the inability of
the lungs to oxygenate the blood,
or the mixture of venous blood
with arterial blood in the heart
or outside. Patient is usually
dyspneic.
Causes
1 . Respiratory failure (page 106)
2. Cyanotic heartdiseases(Fallot's
tetralogy, transposition of
great arteries, Eisenmenger's
syndrome)

Jaundice
Bilirubin is the end product of
hemoglobin metabolism. When its
concentration in the serum rises
above 2 mg%, it becomes clinically -
detectableasayellowdiscoloration
of various tissues and is called
jaundice. It should be looked for in
bright day light as mild jaundice
may be missed in artificial light.
Sites to look for jaundice are:
Skin
Sclera(most reliable site)
Undersurface of the tongue
Jaundice should be differentiated
from an uncommon condition
called hypercarotenemia which .
occurs in people who eat excessive
quantities cif carrots. Skin is yellow
but sclera is white.
Subcutaneous Emphysema
Crackling sensations are felt when the
affected skin is palpated. It is due to
leakage of air from the chest as a result
of penetrating chest injury, accidental
injury to the lung during thoracic
paracentesis, escape of air during
intubation of chest for pneumothorax
or rupture of esophagus. It is also present
in gas gangrene.
Hair Distribution
There is characteristic distribution of
hair in male and female. In female pubic
hair are limited to the pubic area with
horizontal upper border while in male
they spread further up the abdomen
towards the umbilicus in a triangular
pattern.
..
In cirrhosis, the pubic hair distribution
becomes female type in male patients,
and there is loss of axillary hair. In
certain endocrinal disorders, there is
hirsutism (hair growth on face, trunk
and limb of a female).
Pign1entation
In Addison's disease (decreased
production ofcortisol by adrenal glands),
there is dark brown pigmentation of
exposed parts, axillae, palmar creases and
recentscars. Ab1uishblackpigmentation
is also seen in buccal mucosa but it may
be normal in Negroes.
Generalized greyish-bronze color
pigmentation is a feature of
hemochromatosis.
Mask-like pigmentation (also called
chloasma) occurs in pregnancy (it
may occur in women taking estrogen
containing contraceptive pills).
Cafe au lait spots: These are brown
patches of pigmentation seen in patients
of neurofibromatosis.
Albinism: There is congenital absence
ofmelaninpigmentwhichisgeneralized.
Vitiligo: There are patches of white and
darkly pigmented skin. It is associated
with autoimmune disorders. -
Abnormal Sounds and Odors
Stridor is an inspiratory whistling
sound heard in upper respiratory tract
obstruction. Wheeze is similar sound but
occurs in expiration and is due to spasm
of smaller airways.
In hepatic failure there is a sickly odor
in the breath of the patient and is called
fetor hepaticus. In ketoacidosis there is a
sweat smell of acetone in breath.

..
Definitions of Skin Lesions
Macules: These are areas of skin
discoloration which are neither raised
nor depressed.
Papules: These are elevations of· s-kin
which are palpable and diameter is less
than S mm.
Nodules: These are similar to papules
but diameter is more than 5 mm.
Vesicles: These are cystic swellings
containing serous fluid and diameter is
up to S mm.
Pustules: These are similar to vesicles
but fluid is opaque and yellow.
Bullae: These are cystic lesions of more
than 5 mm diameter and are filled with
serous, seropurulent or hemorrhagic
fluid.
Wheals: These are swellings of skin due
to acute localized edema.
Scales: These are formed by abnormal
desequamation of superficial layer of
skin.
Crusts: These are formed by dried
secretions.
Purpura: It means bleeding into the
skin.
Petechiae: These are red lesions 1 - 3
mm diameter due to bleeding and don't
blanch on pressure.
BEDSIDE TECHNIQUES
Ecchymosis: These are large reddish
blue lesions due to bleeding into
subcutaneous tissue and are also called
bruises.
Hematoma: It is palpable fluctuant
collection of blood.
Telangiectases: These are groups of
abnormally dilated small blood vessels.
Spider nevi: These consist of a central
arteriole from which several branches
radiate. When the central arteriole is
obliterated by pressure with a needle, all
the branches are blanched and refilling
starts from the center when needle is
removed.
Campbell de Morgan spots: These are
redswellings, 1 - 2 mm in diameter which
don't fade on pressure and commonly
develop on chest and abdomen with
advancing age.
Erythema nodosum: There are red,
painful, tender, indurated swellings
of variable size (from few millimeters
to several centimeters) mainly on the
shin. Common causes are primary
tuberculosis, streptococcal infection,
sarcoidosis and drugs.
Erythema marginatum: These are
transient pink patches mainly on the
trunk which join to form large areas
with pale center, and are one of the
major criteria of rheumatic fever.

SUMMARY OF GENERAL PHYSICAL EXAMINATION
General appearince
Young or old
Healthy or ill
Normal . --
Physique
Unusually tall or short
Obese, thin or wasted
Puffy
Alert and oriented
Confused
Consciousness Drowsy
Unconscious (test conscious
level using Glasgow coma
scale)
-Posture and attitude Comfortable
Lying in the bed
Dyspneic Lying propped up
Sitting up and bending
forward
In pain
Lying still
Writhing in the bed
Hand
Shape Short metacarpals
Carpal spasm
Size Normal or broad
Pallor
Cyanosis
Koilonychia
Nails Clubbing
Splinter hemorrhages
Leuconychia
Pitting of nails
Osler's nodes
Heberden's nodes
Fingers
Bouchard's nodes
Joint swelling
Deformity of fingers
Arachnodactyly

BEDSIDE TECHNIQUES
Pallor
Palmar erythema
Palm ' Sweating
Dupuytren's contracture
.--
Pulse Rate and rhythm
Blood pressure
Palpatory method
Auscultatory method
General appearance
Moonlike face
Face
Expressionless face
Puffiness
Proptosis
Xanthelasmas
Color of lower conjunctiva
Color of sclera
Rash
Color of skin
Hirsutism
• Parotid glands
Lips
Dryness (dorsum of
tongue)
Pallor or cyanosis
Tongue (dorsum of tongue)
Yellowness
(undersurface)
Size
Inspection
Neck Thyroid
Palpation
Auscultation
Pemberton's sign
Venous pulsations
Neck veins Level of jugular venous
pressure

,t
Lymph nodes
-
Lymph nodes
Axilla (note characteristics if
palpable)
Groin Lymph nodes
Clubbing
Koilonychia
Feet Cyanosis
Loss of hair
Edema
Dorsum of foot
Behind medial malleolus
Edema Shin
Sacrum (bedfast patient
only)
Respiratory rate Count for full minute
Keep the thermometer in the
Temperature
mouth, axilla or groin longer
than recommended by the
manufacturer
11111
Submental
Submandibular
Pre and postauricular
Occipital
Posterior triangle
Anterior triangle
Anterior
Posterior
Lateral
Medial
Central
Apical
Pitting
Non pittingv

.. BEDSIDE TECHNIQUES
WRITING OUT ROUTINE EXAMINATION
An ill looking old man lying in the bed. He is of normal height and built and fully
conscious.
Pulse: SO/minute
BP: 160/95
Respiration: 24/minute
Temperature: lO0"F
Pallor: absent
Cyanosis: absent
Jaundice: absent
Clubbing: absent
Koilonychia: absent
Splinter hemorrhage: absent
Leuconychia: absent
Osler's node: absent
Heberden's nodes: absent
Bouchard's nodes: absent
Interphalangeal joints: normal
Hand deformity: absent
Hand size and shape: normal
Palmar sweating: absent
Palmar erythema: absent
Dupuytren's contracture: absent
Periorbital edema: absent
Proptosis: absent
Skin rash: absent
Parotid gland: not enlarged
Thyroid: diffusely enlarged, nontender, no bruit audible
Neck veins: not engorged
Lymph nodes:
Cervical; two postauricular lymph nodes palpable, 1 cm diameter, discrete, mobile,
nontender, no discharge or sinus.
Axillary; not palpable
Inguinal; not palpable
Ankle edema: present, pitting
Dehydration: absent

Chapter
CARDIOVASCULAR
SYSTEM
Clinical examination of the CVS
(Cardio Vascular System) is particularly
rewarding as it usually leads �o an
accurate diagnosis. Investigations are
carried out, either to confirm the clinical
impression or to differentiate between
various possibilities.
.
SYMPTOMS
Early diagnosis of important cardiac
diseases like ischemic heart disease and
heart failure is based on careful history
taking.
There are two cardinal symptoms of
cardiovascular disease - dyspnea and
chest pain.
Major symptoms of
cardiovascular disease I
Dyspnea Exertional
dyspnea
Paroxysmal
nocturnal
dyspnea
Orthopnea
Chest Ischemic Angina
pain heart disease Infarction
Pericarditis
Dissection of
the aorta
..
Dyspnea
Dyspnea or breathlessness means
difficulty in breathing. It may occur
on exertion or at rest.
Exertional Dyspnea
It is an early symptom of heart
failure. Initially, it may occur after
unaccustomed or strenuous exertion,
but as disease progresses, patient may
become breathless even on walking a
few steps.
Paroxysmal Nocturnal Dyspnea
The patient �akes up at night due to
severe breathlessness which improves
on sitting upright for several minutes,
and is usually accompanied by cough
and frothy sputum. This is called
paroxysmal nocturnal dyspnea. This
is due to transient pulmonary edema,
precipitated by increased venous return
to the heart in recumbent position. It
is a feature of left heart failure; causes
include left ventricular pressure/
volume overload ( hypertension, mitralj
aortic valve disease) and severe left
ventricular disease (ischemic heart
disease, cardiomyopathy).
Orthopnea
In patients of severe heart failure·
breathlessness worsens on lying flat;
this is called orthopnea.

.. Pulmonary edema
There is transudation of flui�
into the alveoli due to left heart
dysfunction. Symptoms are
persistent severe breathlessness, -
orthopnea and cough productive
of copious, frothy, watery, blood
stained sputum.
CHEST PAIN
It is an important symptom of heart
disease. Its characteristics vary with the
underlying pathology.
Ischemic Heart Disease
It means the coronary arteries cannot
maintain adequate blood supply to the
myocardium. It may present as angina
or infarction.
Angina Pectoris
There is transient myocardial ischemia.
The patient develops chest pain on
exertion which is · relieved by rest
and sublingual nitroglycerin. Pain is
retrosternal, across the chest and radiates
to the jaw and left arm. Patient describes
it as a tight band around the chest or
heaviness. It may be associated with
dyspnea, palpitation and sweating. Total
durationofpain islessthan 30 minutes.
Myocardial Infarction
There is total occlusion of one or more
branches of the coronary artery and
the dependent myocardium dies. Pain
is similar to that of angina pectoris but
duration is more than 30 minutes and it
isnotrelievedby sublingual nitrates
or rest.
Pericarditis
Features are similar to the pain of
ischemic heart disease. There is no
effect of rest or nitrates. It is relieved by
BEDSIDE TECHNIQUES
leaning forward and may get worse on
deep breathing and coughing.
Dissection of the Aorta
Pain is severe in intensi�y and is felt in
the back between the scapulae.
Precordial Catch
It is a transient, sharp pain at the site
of the cardiac apex, commonly felt by
normal subjects. It has no significance.
Note: Persistent precordial pain
unrelated to the exertion, is not due to
cardiac disease.
PALPITATION
It is awareness of the heart beat and
is a common feature of anxiety. It also
occurs in tachycardia and heart failure.
Exan1ination
When you are asked to examine a
particular system of a patient, always
start from the general physical
examination except when examiner
asks you to omit it.
Examination of the cardiovascular
system consists of:
1 . Examination of pulse
2. Measurement of blood pressure
3. Examination of neck vein·s
4. Examination of precordium by:
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
Examination of Pulse
The pulse is a wave imparted by the
contraction of the left ventricle to the
blood column and travels 10 times faster
than the blood itself. Pulse is felt where
an accessible artery can be pressed
against an underlying bone.
Commonlyfeltpulsesareradial,brachial,
carotid, femoral, popliteal, posterior
tibial and dorsalis pedis. Pulse becomes

CH 2 CARDIOVASCULAR SYSTEM
impalpable when systolic pressure falls
below 50 mmHg in adults.
Radial pulse: It is the most easily
accessible and the most commonly felt
pulse. The patient's hand should be
slightly flexed and pronated. Press-the
radial artery against the head of the
radius (fig 2.lA).
A
B
,,
,,
',,'
Fig 2.1 : Palpation of (A) radial pulse (B) brachia!
pulse
Brachia! pulse: Flex the patient's arm
and feel for the tendon of the biceps;
press on its medial side with the thumb
of your opposite hand (fig 2.lB).
Carotid pulse: Place the thumb or
fingers of your opposite· hand along the
anterior border of the sternomastoid, at
the level of laryngeal cartilage and press
backwards (fig 2.2). Keep in mind that
carotid sinus (present at the bifurcation
of common carotid artery) may be
stimulated and can result in bradycardia
orsyncopy.Don'tpalpatebothcarotids
simultaneously because blood supply
to the brain may be critically reduced.
..
Palpate the right carotid from the right
· side and the left from the left side.
Fig 2.2: Palpation of carotid pulse
Femoral pulse: Press with the thumb/
finger halfway between the anterior
superior iliacspine andthepubictubercle
along inguinal ligament (fig 2.3A).
A
B
Fig 2.3: Palpation of (A) femoral pulse (8) popliteal pulse

Popliteal pulse: Popliteal artery lies
deep in the popliteal fossaand is difficult
to palpate. Flex the knee at an angle of
120' and push fingets of both hands into
the popliteal fossa (fig 2.3B).
Dorsalis pedis pulse: Palpate in the
proximal part of the first intermetatarsal
space (fig 2.4A).
Posterior tibial pulse: Palpate behind
the medial malleolus (fig 2.4B).
.....,
Fig 2.4: Palpation of (A) dorsalis pedis pulse (B)
posterior tibial pulse
During examination of pulse note
the following features.
1 . Rate
2. Rhythm
3. Volume
4. Character
5. Comparison with other pulses
6. Condition of the vessel wall
BEDSIDE TECHNIQUES
except in certain arrhythmias like atrial
fibrillation.
1 . Tachycardia: It means pulse rate is
more than 100 per minute.
2. Bradycardia: It means pulse rate is
less than 50 per minute.
3. Relative ·bradycardia: Normally
pulse rises 10 beats per minute for
each degree F Cor 0.5'C) rise in the
body temperature. If pulse rate is
slower than expected for the body
temperature, it is called relative
bradycardia.
Rhythm
Normally interval between the beats is
constant and rhythm is regular (fig 2.5).
If it is dis turbed,pulse becomes irregular.
1 . Sinus arrhythmia: Pulse rate is
faster during inspiration andslower
during expiration (fig 2.6). This is a
normal phenomenon and is more
pronounced in certain individuals.
It disappears in heart failure and
autonomic neuropathy.
2. Occasional irregularity: It is due
to premature beats. Premature beat
occurs earlier than expected normal
beat, is weak and is followed by a
longer pause (fig 2.7). Occasional
premature beats are common in
healthy individuals and are not
significant. Frequent premature
beats in a patient with underlying
heart disease should· be taken
seriously.
3. Regularly irregular: Premature
beats occur at a fixed interval
(fig 2.8), eg, after one normal beat
(bigeminy) or two normal beats
(trigeminy). Digox.in toxicity is
the most common cause of such
arrhythmias.
Rate 4. Irregularly irregular:There is no
pattern and beats occur irregularly
Count the pulse for full one minute.
Normal average pulse rate is 72 beats
per minute. It is equal to the heart rate
(fig 2.9). It is easier to detect if rate
is fast.

CH 2 - CARDIOVASCULAR SYSTEM ..
Causes of abnormal heart rate
Tachycardia Bradycardia
Relative
t bradycardia
1 . Exercise
.
2. Anxiety 1 .
3. Fever 2.
4. Anemia
5. Heart failure 3.
6. Hypotension
7. Thyrotoxicosis 4.
8. Tachyarrhythmias
(eg, supraventricular 5.
tachycardia)
Fig 2.5: Normal pulse
--�-
Inspiration Expiration
[ __ Fig 2.6: Sinus a
_
r
_
rh
_
yt
_
h
_
m
_
ia
____�
Fig 2.7: Occasional irregularity
l --Fig ia:"Regularly irregular pulse
[�J
Fig 2.9: Irregularly irregular pulse
Athletes 1 . Enteric fever
Complete heart 2. Viral
block infections
Drugs like digoxin, 3. Meningitis
beta blockers with raised
Raised intracranial intracranial
pressure pressure.
Hypothyroidism
Causes
1 . Atrial fibrillation
2. Frequent multiple premature
beats
3. Atrial flutter with varying block
Pulse deficit: In atrial fibrillation some
of the left ventricular contractions are
weak andarenotconductedtothearteries;
the pulse rate is slower than theheart rate
counted by auscultation. The resulting
difference between pulse rate and
heart rate is called pulse deficit.
Causes of atrial fibrillation
1 . Mitral stenosis
2. Thyrotoxicosis
3. Ischemic heart disease
Volume ofPulse
This is the amplitude of the pulse wave
and is determined by the amount of
displacement of the palpating fingers.
Pulse could be of normal volume
(learnedby experience),high volume (eg,
fever, aortic regurgitation) or low volume
(heartfailure, hypovolemic shock).

..
In younger people it reflects stroke
volume. In old age vessel wall becomes
rigid and pulse voh,1me is higher than
expected for the strbke volume. 3.
Character ofPulse
In certain diseases the pulse wave has a
specific wave form or character. A major
pulse close to the heart (brachial, carotid,
femoral) should be palpated for this
purpose.
1 . Slow rising pulse (pulsus
BEDSIDE TECHNIQUES
cause, but it can also occur in
ventricular septal defect, persistent
ductusarteriosusandsevereanemia.
Pulsus bisferiens: Two systolic
peaks are palpable in one pulse.
(In dicrotic pulse 2nd peak is in
diastole. It is not palpable and is
only seen on direct recording of
the pulse) (fig 2.12). It is sometimes
seen in combined aortic stenosis and
regurgitation.
plateau): It is a low volume pulse,
[ ]
rises slowly and stays longer with
the palpating finger (fig 2.10).
pressure is narrow. It occurs in �
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_-
�
--
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
_
-
-
�
--.
aortic stenosis. Fig 2.12: Pulsus bisferiens
[__�]
Fig 2.1 0: Slow rising pulse
2.
4. Jerky pulse: In hypertrophic
obstructive cardiomyopathyejection
of blood is normal initially. It is
then suddenly obstructed by the
contraction of a band of muscle in
the aortic outflow tract. It gives a
jerky character to the pulse (fig 2.13).
[ J -
I
:::.=========
Fi
=
g
=
2
-
_
-
1
_
3
_
:
=
J
_
e
_
r
=
ky
=
p
=
u
=
ls
=
e
========::::....,
---------------
Fig 2.1 1 : Collapsing pulse
Grasp the patient's wrist with
your right palm in such a way
that radial pulse is felt along
metacarpophalangeal prominences.
Lift the patient's arm suddenly by
grasping his fingers with your left
hand (not with the right hand).
There is increased run:off of blood
towards heart due to effect of the
gravity and collapsing character of
the pulse becomes more obvious.
The collapsing pulse reflects wide
pulse pressure (>60 mmHg). Aortic
regurgitation is the most important
5. Pulsus paradoxus: Pulse either,
becomes weak or impalpable during
inspiration. This is an exaggeration
of a normal phenomenon (2.14).
Cardiac tamponade
Bronchial asthma
Fig 2.14: Pulsus paradoxus

CH 2 - CARDIOVASCULAR SYSTEM
Normally, during inspiration there is
a fall in the systohc pressure, · about
5 mmHg or less; in pulsus paradoxus this
fall is more tharl 10 mmHg. It occurs
in massive pericardial effusion (cardiac
tamponade), constrictive pericarditis and
acute severe bronchial asthma.
Pulsus paradoxus** can be confirmed
by checking the blood pressure during
inspiration and expiration. Ask the
patient to breath quietly. Inflate the
cuffabovesystolic level and then deflate
it gradually. Note the level at which
Krotokoff sounds first appear. These
will be audible during expiration only.
Continuedeflatingthecufftillthesou.nds
remain audible throughout respiratory
cycle and note this level as well. In pulsus
paradoxus difference between these two
levels is more than 10 mm Hg.
6. Pulsus alternans: A strong beat
alternates with a weak beat, but the
interval between beats is constant
and rhythm is regular (fig 2.15). It is
seen in left ventricular failure and
supraventricular tachycardia.
palpatory method. Lower the pressure
in the cuff gradually; at first Krotokoff
sounds for strong beats will appear. Note
the number of these Krotokoff sounds
per minute. Further lower the pressure
in the cuff. When level of systolic
pressure for weak beats is reached, the
rate of Krotokoff sounds will suddenly
become double. This phenomenon will
confirm presence of pulsus alternans.
7. Pulsus bigeminus: It is similar
to pulsus alternans, but interval
between beats is variable. A strong
beat and a weak beat occur close
to each other followed by a long
pause (strong and weak beats are
c6upled), and this cycle is repeated
(fig 2.16). Strong beat is a normal
beat. Weak beat is a premature
beat whicl). occurs earlier than its
expected time, and is followed by
a compensatory pause. Diagnosis
is confirmed on ECG which shows
ventricular bigeminy. Digoxin
toxicityis the most important cause.
l /U'JJJ'f" J l (rJJVf J
L Fig 2.15: Pulsus alternans Fig 2.16: Pulsus bigeminus
Level of systolic pressure is high for
strong beats and low for weak beats;
this helps in confirming the presence of
pulsus alternans by using BP apparatus.
Inflate the cuff above systolic blood
pressure level as determined by the
• In cardiac tamponade only systolic pressure
decreases; diastolic remains unchanged and pulse
pressure is reduced. In bronchial asthma both
systolic ancl diastolic pressures fall during inspiration
and pulse pressure remains unchanged (fig 2.14).
This is due to marked changes in the intrathoracic
pressure which are transmitted to the vessels.
Comparison with other Pulses
Palpate corresponding pulses of both
sides simultaneously and compai'e their
volume except carotids. Don't palpate
both carotids simultaneously (see
page 35). Compare radial and femoral
pulses;in coarctation oftheaorta,femoral
pulse is weak and delayed as compared
to radial pulse (radiofemoral delay)
(fig 2.17).

I
11
Radfofemoraldelay is the most
important clinical feature of
the coarctation of the aorta.
Fig 2.17: Looking for radiofemoral delay
BEDSIDE TECHNIQUES
Condition of the Vessel Wall
Feel the radial pulse with three fingers.
Press with the proximal fingerso that the
pulse is occluded and feel the vessel wall
with the middle finger. Normally it is
not palpable. In advanced atherosclerosis
it can be felt as a cord between finger
and underlying bone.
CHARACTERISTICS OF PULSE
--
I
Characteristics Example Description Causes
Rate + Tachycardia + Pulse rate + Exercise
more than + Anxiety
100/minute · + Fever
+ Anemia
+ Heart failure
+ Hypotension
+ Thyrotoxicosis
+ Tachyarrhythmias
+ Bradycardia + Pulse rate + Athletes
less than 50/ + Complete heart
minute block
+ Drugs (digoxin, beta
block�rs)
+ Raised intracranial
pressure
+ Relative + Pulse rate + Enteric fever
bradycardia is less than + Viral infections
expected
II
for body
temperature
Rhythm + Regular + Interval
I between
the beats is
constant

CH 2 . CARDIOVASCULAR SYSTEM ..
+ Sinus + Pulse rate is + It is a normal
arrhythmia faster during phenomenon and is
inspiration absent in:
Ii
and slower + Heart failure
. -- during + Autonomic
expiration neuropathy
+ Occasional + It is due to + Common in
irregularity occasional healthy persons
in pulse premature + Any myocardial
beats disease
+ Regularly + Irregularity + Digoxin toxicity
irregular comes at
pulse regular
intervals
+ Irregularly + No regularity + Atrial fibrillation
irregular at all + Multiple ectopics
pulse + Atrial flutter with
varying blocks
+ Pulsus + Heart rate is + Atrial fibrillation
deficit faster than Causes
pulse rate + Mitral stenosis
II and it is the
11 difference + Thyrotoxicosis
between the + Ischemic heart
two disease
Volume + Normal + It is learnt by
practice
+ Low volume + Pulse is weak + Heart failure
pulse + Hypovolemic shock
+ High + Pulse is + Fever
volume bounding + Severe anemia
pulse + Aorticregurgitation
Character + Slow rising + Low volume + Aortic stenosis
pulse pulse, rises
slowly and
stays longer
. .with the
finger

.. BEDSIDE TECHNIQUES
+ Collapsing + High volume + Aortic regurgitation
pulse pulse with + Persistent ductus
normal arteriosus
upstroke + AV fistula
but rapid
.-- downstroke
+ Pulsus + Two upstrokes + Combined aortic
bisferiens in one beat stenosis and
regurgitation
+ Pulsus + Pulse becomes + Cardiac tamponade
paradoxus weak or + Acute severe
impalpable asthma
during
inspiration
+ Pulsus + A strong beat + Left ventricular
alternans alternates failure
with a weak + Supraventricular
beat and tachycardia
the interval
between them
is constant
+ Pulsus + Strong and + Digoxin toxicity
bigeminus weak beats are (ventricular
coupled and bigeminy)
are followed
by a longer
pause
Comparison + Radio- + Femoral pulse + Coarctation of aorta
with other femoral is delayed
pulses delay 11 compared
with radial
pulse

CH 2 - CARDIOVASCUlAR SYSTEM
MEASUREMENT OF BLOOD
PRESSURE
The Blood Pressure (BP) is the product
of the heart rate, strnke volume and
peripheral resistance. There are t�_Q
levels - systolic and diastolic.
There are two types of blood pressure
apparatuses (sphygmomanometers)
in common use. In Mercury
Sphygmomanometer a column of
mercury moves up and down in a
calibrated vertical glass tube as the cuff
is inflated and deflated (fig 2.18). In
AneroidSphygmomanometer a spring is
connected to a needle; when the pressure
in the cuff changes, this needle moves
on a dial and indicates pressure (fig
2.19). This is less reliable and should be
frequently compared with a mercury
sphygmomanometer.
["Ag 2.18: Blood pressure apparatus; Mercury t�
Fig 2.19: Blood pressure apparatus; aneroid type
..
Method
Patient should be resting and relaxed,
sitting or lying. Place the manometer at
the same level as cuff on the patient's
arm (this is not necessary if aneroid
type of sphygmomanometer is used).
The cuff should be wide enough to cover
about two thirds of the arm length.
Higher reading is obtainedif asmall cuff
is used. The length of the cuff should be
about 80% of the circumference of the
limb and width should be 40% of the
circumference of the limb (fig 2.20) A
standard adult -cuff is 12.5 cm wide. In
children smaller cuffs are used.
Length
Cuff
Fig 2.20: Blood pressure apparatus cuff; length is
equal to 80% of the limb's circumference, width is
equal to 40% of the limb's circumference
Removeall theclothing from the upper arm.
Apply the cuff closely to the upper arm in
such a way that its lower border is not less
than 2.5 cm (l") above the cubital fossa and
tubing is on the medial side (fig 2.21)
Fig 2.21 : Application of cuff to the arm; distance
from the cubital fossa should be at least 1 inch

11111
Palpatory Method
Feel the radial pulse (fig 2.22). Inflate the
cufftoapressureabovethelevelatwhich
the radial pulse becomesimpalpable and
then gradually deflate it. The level at
which the radial pulse becomes palpable
again is taken as the systolic pressure.
It is a few mmHg less than the systolic
pressure measured by the auscultatory
method. Deflate the cuff completely.
Fig 2.22: Measuring BP: palpatory method
Auscultatory Method
Palpate the brachial artery which lies
on the medial side of the tendon of the
biceps.
Place the stethoscope lightly over it
(fig 2.23) and inflate the cuff above
the systolic level determined by the
palpatory method.Lower the pressure in
the cuff by 5 mmHg at a time. The level
at which the Krotokoff sounds are heard
for the first time is the systolic pressure.
The Krotokoff sounds become louder as
the pressure is loweredfurther; suddenly
they become faint (phase IV) and then
disappear (phase V). The level at which
sounds disappear is the diastolic pressure
(fig 2.24A). In certain high cardiac
output states the sounds remain audible
at a very low level. In these situations the
BEDSIDE TECHNIQUES
level at which fainting of sounds (phase
IV) occurs is taken as the diastolic level.
Fig 2.23: Measuring BP: auscultatory method
1 30
75 IV -
70 V
0 --'--- -
A
1 90
1 60
1 40
1 20
1 1 2
Si lent g ap
0 �---
8
I Fig 2.24: (A) normal Krotokoff sounds (B) silent gap
Normal Blood Pressure
It varies with age. In adults· <130/85 is
normal, 130-139/85-89 is high normal and
140/90 or above is hypertension. Blood
pressure is lower in children and women
and higher in elderly.
Pulse pressure: It is the difference
between the systolic and the diastolic
pressure. Normal range is 30 - 60 mmHg.

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