THE RESPIRATORY SYSTEM

HISTORY
You have to be able to fully explore common symptoms of respiratory disease. The most common
symptoms of respiratory disease are:

Shortness of Breath (Dyspnoea)

Chest pain
Cough
Wheeze
Sputum production
Haemoptysis

Remember that these symptoms can also occur in the absence of respiratory disease. Complete the
table below by listing some common respiratory and non-respiratory causes of each symptom.

Primary Non-Respiratory
Symptom Respiratory Causes Causes
Dyspnoea

Chest Pain

Cough

Sputum production

Hemoptysis

Wheeze

use the pneumonic SQITARPS to help you explore these symptoms. For example there are
many questions that could be asked about a chest pain:

Site: where is the pain?

Quality: What does the pain like? E.g. sharp, blunt, piercing or burning?

Intensity: Is it disruptive to the patient's life?

Timing: How long has it been present and has it changed over this time?
Does it change during the course of a day?

Aggravating factors e.g. damp conditions, smoking, dust?

 Relieving factors: e.g. changing position, analgesia?

Previous episodes: Is there a pattern – time of year, weather, work? Was

it the same or different from this presentation?

Secondary symptoms: ask about other symptoms of respiratory disease

and establish the relationship between them

Try using SQITARPS to consider the types of questions that you could ask about cough by
completing the table.

Cough and sputum

Site
Quality
Intensity
Timing
Aggravating factors
Relieving factors
Previous episodes
Secondary symptoms

Symptoms do not often occur in isolation and the presence or absence and features of secondary
symptoms will help you to make a diagnosis. Asthma and Chronic Obstructive Pulmonary
Disease (COPD) have common symptoms but full exploration of these will reveal characteristic
differences. Complete the table to describe the features of each symptom in Asthma and COPD
respectively.

Dyspnoea Cough Sputum

Asthma

COPD
Physical Examination - Respiratory Preparatory Worksheet

1. Name the main muscles involved in:

A- Inspiration

B- Expiration

2. Mark on the following diagram the surface markings of the lobes of the lungs

3. Which lobes of the lungs are best examined from:

A- the anterior chest

B- the posterior chest

4. Haemoptysis
A- What is haemoptysis?
B- In what conditions might this be a feature?

5. Wheeze
A- Describe what is meant by the term „wheeze‟
B- When does wheezing occur, in inspiration or expiration, and why
C- What processes in the lungs lead to narrowing of:
i. the large airways
ii. the small airways

6. Which structures in the thorax are:

A- well endowed with pain fibres

B- poorly endowed with pain fibres

C- What is the significance of this for how patients experience pain in

respiratory conditions?
7. List four occupations which are particularly associated with lung disease
A-
B-
C-
D-

8. Explain what the terms „vesicular‟ and „bronchial‟ breath sounds mean

9. Mark on the diagram those areas where you would expect it to be dull to percussion in
a normal individual

10. Consolidation
A- What is meant by the term „consolidation?‟

B- What pathological processes may lead to consolidation?

C- Mark on the diagram the area that would be dull to percussion in an

individual with consolidation of the right lower lobe
11. Pleural effusion
A- List three circumstances in which excess fluid will accumulate in the
pleural space

B-What would be the features of pain experienced in these

circumstances?

C-What are the percussion notes in such disease?

D- What are the auscultation notes in such disease?

E- Where would you best aspirate this fluid from his chest?

F- What is the preferred site for chest tube thoracostomy to put in case it
is needed in such patients?
THE RESPIRATORY SYSTEM
PHYSICAL EXAMINATION
Overview
The respiratory examination should include the following:
- General inspection from the end of the bed.
- General examination of:
Hands / pulse
Face
Neck
- Examination of the chest – repeated on the anterior and then the posterior chest wall.
Inspection
Palpation
Percussion
Auscultation

Preparation
Wash your hands
Introduce yourself to the patient if you have not already done so and check
the identity of the patient
Ask the patients permission to carry out the examination
Give a brief explanation to the patient before you start. Further
explanation/instructions can be given as you proceed.
Equipment
o Stethoscope
o Peak Flow meter
Patient position
Ideally the patient should be sitting at 45 degrees with the whole of the chest
exposed
In female patients the bra will need to be removed for you to carry out the
examination effectively. Do not expose the patient's chest until you are ready
to examine.

General Observations
- Look at the patient from the end of the bed. Note:
Obvious discomfort/pain
Breathlessness, colour of the face
Use of accessory muscles, tachypnoea, audible breathing (e.g. wheezing,
strider).
Note the respiratory rate (count for at least 30 seconds)
Items around the bed (e.g. oxygen, chest drain, sputum pot, inhaler, nebulizer) Hands
Inspect both hands; nails, back and palms.

You should be able to recognise and know the significance of the following:
clubbing
peripheral cyanosis
temperature
tar staining
Pallor
Splinter haemorrhage

- Feel the radial pulse. Note the rate, rhythm and character
Tachycardic, bounding pulse in CO2 retention
Check for flap of CO2 retention if appropriate
Ask patient to stretch arms out in front of them with the wrists dorsiflexed and
fingers extended.
Look for irregular, jerky flexion/extension at the wrists and MCP joints

Face
Gently pull down lower eyelids and ask patient to look up.
Inspect for pale conjunctiva of anaemia
Ask patient to open their mouth and stick their tongue right out and then to the
ceiling.
Look for central cyanosis – inspect the lips and the tongue

Neck
Anatomical arrangement
Cervical LN are arranged in two circular and longitudinal patterns
The outer circle of LN groups includes
Submental ( level Ia)
Submandibular ( level Ib)
Pre-auricular ( Parotid)
Post-auricular (Mastoid)
Occipital ( level Vb)

The inner circle of LN group includes

Palatine tonsils
Lingual tonsil
Adenoid tonsil
Tubal tonsils
The superficial longitudinal LN groups (level VI) includes
Prehyoid
Pre- and paralaryngeal
Pre- and paratracheal

The deep longitudinal LN groups includes right and left

Upper deep jugular (Also called tonsillar or jugulo-diagastric ) (level II)
Middle deep jugular (Also called jugulocarotid)(level III)
Lower deep jugular (Also called jugulo-omohyoid)(level IV)

Additional cervical LN groups include

Supraclavicular (level Va) (with the occipital forms posterior triangle LNs)
Scalene Nodes (Subgroup of Supraclavicular)
Upper mediastinal (level VII)

Palpate for enlarged lymph nodes

Always take permission
Seat the patient in a chair comfortably
Examine the patient from the back.Start with the outer circle from anterior
(submental) to posterior (occipital) bilaterally simultaneously.
The deep circle is usually assessed with the help of indirect laryngoscope in
ENT department.
The deep longitudinal LN groups are examined each side alone from above
downwards with head in neutral position and slightly tilted to one side. Never
examine right and left side at the same time (carotid sinus stimulation and risk
of vasovagal shock)

The Supraclavicular LNs are examined bilaterally simultaneously from

behind with the shoulders shrugged.
Scalene nodes are examined with head slightly tilted to one side. Press down
gently between clavicle and sternocleidomastoid toward first rib. Enlargement
may be the first evidence of metastatic lung cancer.

The Chest
The chest wall must be examined completely (inspection, palpation, percussion, auscultation),
first the whole of the front and then the whole of the back. Examine from side to side and not top
to bottom so that you can make comparisons.
Lymph nodes can be palpated whilst the patient sits up in between.

INSPECTION - ANTERIOR
With the chest exposed look carefully for
- Chest wall abnormalities e.g.
barrel chest
pectus carinatum
pectus excavatum
Harrison's sulci
kyphosis and scoliosis.

- Breathing pattern and asymmetry of movement

- Incisions and scars
Site
Length
Phase (inflammatory, proliferative, or remodeling and maturation phases )
hypertrophic and keloid
sinus or granuloma

PALPATION – ANTERIOR
- Tracheal deviation
o Warn the patient it may be uncomfortable and place a finger either side of the trachea,
judging the space each side.
o Should lie centrally.

- Chest expansion.
o Place hands around the chest, with thumbs extended and elevated from the chest wall
o Ask the patient to take a deep breath in and then out.
o Your thumbs will move apart. Note the amount and symmetry of movement.

PERCUSSION – ANTERIOR
- Start from the clavicles and move from side to side down the chest wall and under the arms. The
diagram below shows where you should percuss the chest wall.

- You should be able to describe the percussion note produced and know its significance.
i.e.
Tympanic
 Hyper resonant
Dull
- Each area of the chest wall correlates with different areas of the lungs in both percussion
and auscultation.
anterior wall - upper lobes
posterior wall - lower lobes
right lateral wall - middle lobe
left lateral wall – lingual

Percussion Place left hand flat on the chest wall. Press the middle finger firmly against the
chest. Using the middle finger of the right hand, strike the middle phalanx of the middle
finger of the left hand. The striking finger should be moved away again quickly so as not to
dampen the sound produced. Movement of the striking hand is from the wrist.

AUSCULTATION – ANTERIOR
Breath Sounds
- Ask the patient to keep breathing in and out through the mouth
o Bear in mind the comfort of the patient – too many deep breaths may become distressing
- Starting above the clavicle, listen at the same places that you percussed.
- Compare side to side and listen during both inspiration and expiration

Vocal Resonance
- Ask the patient to keep repeating "ninety-nine‟ while you listen in the same places again using the
diaphragm of the stethoscope comparing side to side
- You should be able to recognise changes in the transmission of sound and understand
their significance,

POSTERIOR CHEST EXAMINATION

Repeat inspection, palpation, percussion and auscultation on the posterior chest.

Completing the Examination

- Cover patient /assist to re-dress if necessary
- Thank the patient
- Bed side tests
o Peak flow
o Temperature
- Inspect sputum sample
- It is important to note that in the clinical setting, the respiratory system should not be examined
alone, but in conjunction with a cardiovascular examination, including looking for peripheral
oedema
Respiratory Examination Checklist

Preparation √ Comments
Introduction
Consent and explanation
Wash hands
Position patient appropriately

General Inspection √ Comments

Obvious discomfort/pain
Colour
Is the patient breathing
comfortably?
Any audible wheeze or stridor?
Respiration rate
Items of notes around the patient

Hands √ Comments
Clubbing
Peripheral Cyanosis
Cigarette tar stains
Radial Pulse
CO2 retention Flap

Face √ Comments
Conjunctiva (anaemia)
central cyanosis

Chest Inspection Anterior Posterior Comments

Asymmetry
Scars
Shape/deformities

Chest Palpation Anterior Posterior Comments

Trachea ----------
Chest expansion

Chest Percussion Anterior Posterior Comments

All areas
Compares side to
side
 Chest Anterior Posterior Comments
Auscultation
Breath sounds
Vocal resonance

Lymph nodes √ Comments

Occipital
Post-auricular
Pre-auricular
Submandibular

Submental
Anterior and posterior cervical
Supraclavicular (including for
Scalene)

Completing the Examination √ Comments

Perform Peak flow reading
Examine any sputum
Temperature

THE RESPIRATORY SYSTEM CASE

STUDIES

1. Mrs. Hameeda is a 76 years old lady, has been admitted with a 3-day history of increasing
breathlessness, fever and a productive cough (green sputum). On examination, she is
cyanosed, disorientated, and breathless at rest. There is reduced expansion at the right
base, dullness to percussion and bronchial breathing on auscultation.

a. What is the likely diagnosis?

b. What features of the history and examination support this?

c. Why does this patient have bronchial breathing?

2. Miss Sahar is a 26 yr old female who has just arrived at casualty by ambulance.
She is complaining of chest pain. On questioning, you find that the pain is a ‘sharp’ pain on the
left side of the chest, under the breast and radiating to the left shoulder. The pain started very
suddenly, about 1 hr ago while she was hanging out washing, and has been constant since.
Shortness of breath began at the same time as the pain and neither is relieved by resting or
sitting. Coughing and inhaling deeply make the pain and shortness of breath worse. She has had
a productive cough (clear sputum streaked with blood) for the past 30 minutes. This is the
first time she has ever had anything like this.

a. You have already explored the presenting complaint. What further questions would you want to
ask to explore the rest of the history, for example past medical history?

b. The patient is worried that the pain may be related to her heart. Do you agree and why?

c. List the typical features of cardiac and pleuritic pain.

Cardiac Pain Pleuritic Pain

3. A 22 yr old male victim of a hit and run has arrived in casualty. He is tachypnoeic,
tachycardic, hypotensive, centrally cyanosed and agitated. On examination, you find a large bruise
on the front of his right chest; displacement of the trachea towards the left, reduced right chest wall
movement and crepitus over the bruise. The right lung is hyper resonant on percussion with no breath
sounds on auscultation. You diagnose a tension pneumothorax.
A- Why is this patient cyanosed and agitated?

B- Why has the trachea deviated to the left?

C- List one other condition which will cause a mediastinal displacement away from the affected
side and explain why.

D- List two conditions which will cause a mediastinal displacement towards the affected side
and explain why.

E-What is the immediate measure to be taken?

4. Ahmed is a 44 yr old male who has presented to his GP with a non-productive cough and
feeling short of breath at night. He has had the cough for approximately 1 week and
first noticed he felt breathless the night before last. The cough has been worse at night. Last
night, he was wheezing and feeling as though he was ‘unable to breathe properly’. The episodes of
breathlessness and wheezing lasted for a few hours. He thinks that the episodes may be due
to feeling anxious about his new job, as he recently went back to work.

a. You have already explored the presenting complaint. What further questions would you want to
ask to explore the rest of the history, for example past medical history?

b. List the symptoms of bronchitis and asthma that may be elicited from the patient when taking a
history

Asthma bronchitis

c. What other questions would you want to ask to distinguish between bronchitis and asthma in Ahmed's case?

5. Ali is , an 18 years old known asthmatic, has been admitted as an emergency to casualty,
due to severe difficulty breathing.

a. What questions would you want to ask to fully explore the difficulty breathing?

b. What would you expect a healthy 18 years olds Peak Flow reading to be?

c. What would you expect to find on testing Ali's Peak Flow, and why?

6. Anas is a 4 year old child was referred by a pediatrician because of repeated attacks of severe
chest infection (three in number) during the last month that usually resolved by antibiotics,
expectorants and mucolytics, but the last attack did not resolve. On examination the lower
right lobe of the lung showed no air entry and wheeze by auscultation. A chest x-ray
revealed an opacified lower right lobe. Temperature 38 C, pulse 120/min and respiration
rate 35/min. You suspect a foreign body inhalation.

a. What question would you want to ask to interpret the recurrent chest infections?

b. What is the cause of the wheeze?

c. What do expect to find on chest X ray?

d. How can you explain the presence of tachypnia and tachycardia ?

e- What is the lesson taken from this scenario? (ie. Repeated chest infection in a toddler)

7- Mr. Kasim, a 65 years old heavy smoker male, is presented with productive cough which
is blood-stained, associated with shortness of breath. You suspect a lung cancer.

A- What other questions would you ask to investigate his bloody cough?

B- What do expect to find on chest auscultation?

C- What are the CXR findings?

D- One week later, he complained from severe pain in medial part of his right
hand and forearm. How can you explain this?

E- Surgery involved right pneumectomy (lung resection), what do expect to

find on percussion and auscultation?

F- What are the CXR findings now?

8- A 34 years old male is presented chronic cough, associated with night fever and profuse
sweating. A pulmonary tuberculosis is suspected.
A- What do you ask to investigate his fever?

B- What are the physical signs on hand examination?

C- What are the expected CXR findings?

THE GASTROINTESTINAL SYSTEM
HISTORY

You need to know common causes of, and be able to fully explore common symptoms of
the following gastrointestinal and genitourinary symptoms:
Dysphagia
Heartburn and acid reflux
Dyspepsia
Nausea, vomiting, haematemesis
Abdominal Pain
Altered bowel habit
Rectal bleeding and melaena
Abdominal distension
Anorexia and weight loss
Urinary and Prostate symptoms (See separate section)

Remember that these symptoms do not always have alimentary causes. Complete the table below by
listing some common causes of each symptom.

Symptom GI Non GI
Vomiting
Dysphagia
Abdominal distension
Anorexia/Weight loss
Altered bowel habits

Think about how you can use the mnemonic SQITARPS to help you explore these
symptoms. For example there are many questions that could be asked about vomiting

Site: The quality of the vomit often gives an indication of the site of the
problem.
Quality: What are they vomiting? E.g. food, bile, blood. If blood is it fresh
and red or partially digested (like coffee grounds).
Intensity: How frequent or forceful is the vomiting? What volume? Are there
signs of hypovolaemia in haematemesis? Are they actively vomiting or does
blood well up in the mouth?
Timing: How long has it been present and how has it changed over this time?
E.g. food initially and then blood. Does it change during the course of a day?
Aggravating factors: Are they on any medication? Eating? Alcohol?
Relieving factors: Have they taken any medication?
Previous episodes: Is there a pattern?
Secondary (or associated) symptoms: Ask about other GI symptoms, consider
neurological symptoms, trauma, weight loss
Try using SQITARPS to consider the types of questions that you could ask about altered bowel
habit by completing the table. Consider why the information might help you to make a diagnosis.
Remember that they will not all be relevant for every symptom.

Site
Quality
Intensity
Timing
Aggravating factors
Relieving factors
Previous episodes
Secondary symptoms

Symptoms do not often occur in isolation and the presence or absence and features of secondary
symptoms will help you to make a diagnosis. Irritable Bowel Syndrome (IBS) and Ulcerative
Colitis have common symptoms but full exploration of these will reveal characteristic
differences. Complete the table to describe the features of each symptom in IBS and Ulcerative
Colitis respectively. Don‟t forget to explore secondary symptoms.

Point Abdominal pain Change in bowel habits

Irritable bowel syndrome

Ulcerative colitis

Physical Examination - Gastrointestinal

Preparatory Worksheet

1. Identify on the diagram, the bony landmarks of the abdomen. Ensure you
include
The costal margins
The xiphisternum
The 12th rib
The iliac crest
The iliac tubercle
The anterior superior iliac spine (ASIS)
The inguinal ligament
The pubic symphysis
2. Draw and label on diagram
A. the four quadrants of the abdomen
B. the nine segments of the abdomen and name the lines or planes that
delineate these segments.
3. Mark on the diagram the surface markings of the following:
o Domes of right and left diaphragm
o Stomach
o Spleen
o Tip of gall bladder
o Transpyloric plane (L1)
o Subcostal plane (L3)
o Intercestal plane (L4)
o Transtubercular (L5)
o Interspinous plane (S1)
o Cocygeal plane
o Bifurcation of the aorta
o Confluence of IVC (inferior vena cava)

4. Name 10 structures located on the transpyloric plane

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
5. Abdominal pain
a. What is meant by the term "colicky‟ in relation to pain?

b. Which abdominal structures may produce colicky pain?

c. How does the intensity of colicky pain change over time and why?

d. List the viscera which commonly perforate.

e. What sort of pain would occur with a perforation of a hollow viscus?

f. How would this pain vary over time and why?

g. What is meant by the term "guarding?‟

h. What is meant by the term "rebound?‟

i. What is referred pain?

j. What is radiated pain?

k. What is shifting pain?

l. Give three examples of referred pain arising from the abdomen
B.
C.
D.

6. Melaena
a. What is melaena?

B . List five common causes of melaena

A. ……………
B. …………....
C. ……………
D. ……………
E. …………...

7. Mark on the diagram the characteristic sites where pain is felt from:
a. The oesophagus
b. The stomach
c. The pancreas
d. The gallbladder
e. The small intestines
f. The descending colon
g. The kidneys
h. The urinary bladder
7. List six causes of abdominal swelling (6 Fs)

A.
B.
C.
D.
E.
F.
G.

8. Hernias
a. What is meant by the term "hernia‟?

b. What are the common hernial orifices of the peritoneal cavity?

c. What is the difference between a direct and an indirect inguinal hernia?

THE GASTROINTESTINAL SYSTEM

PHYSICAL EXAMINATION

Overview

The abdominal examination should include the following: A. General

inspection from the end of the bed.

B. General examination of:

Hands / pulse
Face and neck ( including lymph nodes)
Feet and legs

C. Examination of the abdomen.

Inspection
Palpation
Percussion
Auscultation
Associated things related to abdomen
Preparation
Introduce yourself to the patient if you have not already done so and check the
identity of the patient
Wash your hands
Ask the patients permission to carry out the examination
 Give a brief explanation to the patient before you start. Further
explanation/instructions can be given as you proceed.
Equipment
A. Stethoscope
B. Pair of gloves
C. Tongue depressor
D. Thermometer

Patient position: Ideally the patient should be lying flat with the head propped
on a single pillow and the arms at the sides.
Exposure: When you are ready to examine the abdomen it should be exposed
from above the costal margins to the level of the symphysis pubis(mid-thighs
is better to inspect the groins well).
General Observations
Check visually from the end of the bed. Note:
Obvious discomfort/pain, breathlessness, distension
Colour
Items around the bed (e.g. catheter bag, cannulas, NG tubes, drains, IV fluids)

HANDS
Inspect both hands; nails, back and then palms.
You should be able to recognise, and know the significance of, the following:
Anaemia
Dehydration
Clubbing
Leukonychia
Koilonychias
Palmar erythema
Dupuytren's contracture
Spider-naevi
Muscle wasting (Thenar, hypothenar, and interossei)

Feel the radial pulse. Note the

Rate
Rhythm
Volume

Check for hepatic flap of liver failure (if appropriate)

Ask patient to stretch arms out in front of them with the wrists dorsiflexed and
fingers extended.
Look for irregular, jerky flexion/extension at the wrists and MCP joints
EYES
Gently pull down lower eyelids and ask the patient to look up. Inspect for:
pale conjunctiva of anaemia
yellow sclera of jaundice - ideally in natural light (upper eyelid)

MOUTH
Ask patient to open their mouth. Inspect the teeth, tongue, gums and inner surface of the cheeks
You should be able to recognise, and know the significance of the following:
Ulcers
Candidiasis
Changes to the tongue e.g. glossitis, macroglossia.

Note any obvious odour of the patients breath e.g.

Fetor hepaticus
Ketosis
Uraemia
Acute appendicitis

Neck
Palpate for enlarged lymph nodes
Remember that cervical LN are arranged in two circular and longitudinal patterns

The outer circle of LN groups includes

Submental
Submandibular
Pre-auricular ( Parotid)
Post-auricular (Mastoid)
Occipital

The inner circle of LN group includes

Palatine tonsils
Lingual tonsil
Adenoid tonsil
Tubal tonsils
The superficial longitudinal LN groups (level VI) includes
Prehyoid
Pre- and paralaryngeal
Pre- and paratracheal

The deep longitudinal LN groups includes right and left

Upper deep jugular (Also called tonsillar or jugulo-diagastric )
Middle deep jugular (Also called jugulocarotid)
Lower deep jugular (Also called jugulo-omohyoid)
Additional cervical LN groups include
Supraclavicular (check for Virchow‟s Node)
Scalene Nodes (Subgroup of Supraclavicular)
Upper mediastinal

THE ABDOMEN
INSPECTION
With the abdomen exposed, you should be able to recognise, and know the
significance of, the following:
Abdominal distension and asymmetry
Umbilicus (normally inverted)
Focal swelling
Mode of respiration (Abdomino-thoracic or thoraco-abdominal)
Movement of abdomen with respiration (absent in peritonism)
Dilated/prominent veins
Visible peristalsis
Obvious pulsation
Skin discolouration or pigmentation or tattooing.
Hair distribution
Scars
Surgical stomas (ileostomy, colostomy, conduit,…etc)
Cough impulse and look at both groins, periumbilical area, epigastric area,
scars and stomas to detect corresponding hernias

PALPATION
You should be at the same level as the patient to palpate the abdomen, looking at the patients face
for any signs of discomfort. Remember to examine any areas of tenderness last. Ask the patient
if they have any pain before commencing.
The abdomen should be examined by light (superficial) and deep palpation in all 9 areas before
examining specific organs checking for masses or tenderness. The order they are examined in does
not matter.
Light Palpation

Gently palpate all nine areas

Start away from known pain.
Hold your hand flat, and gently press in by extending at the MCP joints to
palpate with the palmar surface of your finger - not digging in with your
fingertips.

Rebound Tenderness
pain is worse when you release pressure on the abdomen than when you press down - this is a sign
of peritoneal irritation
If there is pain on light palpation, try and determine if this is rebound tenderness
Deep Palpation
Re-examine using the same technique but now using more pressure. Note any masses or structural
abnormality. Masses should be described in terms of
Site
Size
Shape
Surface
Consistency
Mobility
Layer of origin (skin, subcutaneous tissue, abdominal wall, or intraabdominal)
Overlying skin (erythema, ulceration, scar. …etc.)
Cough impulse
Compressibility and reduccibility
Movement with respiration.
Tenderness
Hotness
Percussion note
Fluctuation
Pulsatility and expansility
NOTE: Two signs are relevant to judge the origin of the abdominal mass
Carnette's sign and Fothergill's sign

The Liver
The liver normally is either not palpable or just palpable 2 cm below right costal
margin. Span is 12-16 cm.
Start palpation from the right iliac fossa using the same technique as before but angle your hand so
that the index finger is aligned with the costal margin .
Ask the patient to take breaths in and out as you proceed, and feel for the descending liver edge on
inspiration If the liver is not felt move your hand 1-2cm superiorly
toward the right hypochondrium during expiration, ready to apply gentle pressure
again during inspiration
Repeat this process until the liver edge is palpated or you reach the costal margin.
Describe your findings
Note how far beyond the costal margin the liver extends in centimetres
Its span
Is its edge sharp or rounded
Is the surface smooth or irregular?
Is there any tenderness?
Practice Tip!
The liver edge is sometimes palpable just below the costal margin at the height of inspiration in
normal healthy individuals. Practice your technique on your colleagues
The Spleen
Start palpation from the right iliac fossa moving diagonally toward the left hypochondrium
. Ask the patient to take breaths in and out as you proceed and use the same technique as for the liver
Describe your findings as for the liver.
In healthy individuals the spleen is not palpable. It enlarges along the line of the 9 rib and moves
downwards and inwards on inspiration. The spleen has a distinctive "notch‟ which can help to
differentiate it from other structures in splenomegaly. The
odd numbers 1,3,5,7,9, and 11 signify anatomical facts of the spleen (dimensions in inches, weight
in oz., and delineating ribs). The spleen needs to enlarge 2-3 times its normal size to be palpable.
Mild splenomegaly (SM): just palpable below left costal margin. Moderate
SM : reaches beyond half the way to umbilicus.
Massive SM: reaches beyond umbilicus.

Describe your findings

Note how far beyond the left costal margin the spleen extends in centimetres
Is its edge sharp or rounded
Is the surface smooth or irregular?
Is there any tenderness?
Enumerate the common causes of massive splenomegaly
A.
B.
C.
D.
E.

The Kidneys
The kidneys are not normally palpable; however, you may feel the lower pole of the right kidney in a
thin person. Place your left hand behind the patients back just below the ribs at the right hand side
Place your right hand on the abdomen below the right costal margin just lateral to the rectus
abdominis. Ask the patient to breathe out and push your hands together firmly (but gently). Ask the
patient to breathe in. You may feel the lower pole of the kidney moving down between the hands If
this happens try to "Ballot‟ or push the kidney back and forward between your hands Repeat for
the
left kidney by leaning over and placing the left hand under the left loin.
Practice Tip!
The right kidney lies a little lower than the left. The lower pole of the right kidney may be
palpable in normal, thin individuals.

Ballotting the Kidney

This demonstrates the mobility of the kidney - helping to confirm what the structure is.
How can differentiate enlarged spleen from left kidney
1- The spleen has a notch.
2- The spleen is palpated with one hand, while the kidney with two hands.
3- The spleen is dull to percussion while the kidney is tympanic due to overlying
colon.
4- The spleen moves more with respiration than the kidney.
5- The spleen enlarges diagonally towards RIF, while the left kidney moves
towards LIF.
6- The spleen cannot be balloted , in contrast to the kidney.

Bladder
Palpable suprapubically if full. Start palpation from umbilicus with index finger horizontal
and proceed inferiorly toward symphysis pubis

Aorta
Palpate in the vertical midline of abdomen above the umbilicus.
Place the fingers on either side of the outer margins, feeling for pulsation
Normal diameter is 2-3cm
Palpable in most healthy people

PERCUSSION
You should percuss any lumps or masses identified on palpation to determine their size and
nature
Percuss individual organs to help determine their size (you may see some clinicians percuss the 9
regions)
If the abdomen appears distended and you suspect the presence of ascites test for "shifting
dullness‟ and "fluid thrill"
Percussion may reveal enlargement of the spleen that is not detectable on palpation. This is because
the spleen would have to be 2-3 times its normal size to be palpable on abdominal examination

The Liver
Percuss from right iliac fossa upwards
Identify both the lower and upper borders of the liver
Note the length in centimetres at the midclavicular line is called span
The Spleen
Percuss from the right iliac fossa diagonally toward the left hypochondrium. Continue percussing
over the ribs toward the midaxillary line and lower left ribs for dullness.

Bladder
Begin percussing from just above the umbilicus with the finger positioned horizontally
on the abdomen Percuss inferiorly toward the symphysis pubis.
Ascites and Shifting Dullness
Ascites is free fluid within the peritoneum. With the patient lying on their back, gravity will
cause the fluid to move toward the patients back and the bowel will float centrally. When the patient
is rolled to onto their side, the fluid will be moved by gravity to the side they are lying on. On
percussion any dullness caused by the presence of fluid will also move.
Percuss from the centre of the abdomen laterally with the fingers positioned
longitudinally until dullness is detected.
Keep your finger pressed there (or mark the spot with a pen) as you ask the
patient to roll on to the opposite side to where you have marked
Wait at least 30 seconds
If the dullness was an air/fluid level, the previously dull area will now be
resonant as fluid is moved away by gravity.
Repeat percussion moving from this point back toward centre

Fluid Thrill
Place your left hand flat against the left side of the patients abdomen.
Ask the patient to place the edge of one hand longitudinally on midline of
abdomen to prevent transmission of the impulse via the skin.
Tap on the right side of the abdomen with the right hand.
Feel for a ripple of fluid against the left hand.
Practice Tip!
Practise listening to as many abdomens as possible to recognise the range of sounds produced by
normal peristalsis

AUSCULTATION
Bowel Sounds
Listen with the diaphragm of the stethoscope just below the umbilicus. Describe findings you
should be able to recognise and understand the significance of:
Normal
Tinkling
Absent bowel sounds.
You may have to listen for a while if the sounds are quiet (usually 1-2 minutes)

Bruits
Listen with the diaphragm of the stethoscope for turbulent blood flow
Over the aorta, just above the umbilicus
Over the renal arteries - just above and to either side of the umbilicus
Over the liver (Cruveilhier bruit)
ASSOCIATED THINNGS RELEVANT TO ABDOMINAL EXAM
Before completion, you should also consider:
1. Examination of hernial orifices (inguinal and femoral)
2. Digital Rectal Examination (DRE)
3. Per vaginal examination (PVE)
4. Examination of external genitalia
5. Examining the left supraclavicular fossa for LN (Troisser's sign in
abdominal malignancies)
6. Examining back of the abdomen for
Scars
Hernias (lumbar)
Bed sores
Lumps
Sacral oedema
Sinus (Pilonidal)

Completing the Examination

Cover patient /assist to redress if necessary
Thank the patient
Bed side tests
o Blood Pressure and Temperature
o Urine dipstick

Gastrointestinal Examination Checklist

Preparation Comments
Introduction
Consent and explanation
Wash hands
Position patient appropriately

General Inspection Comments

Is the patient breathing comfortably?
Conscious Level?
Is the patient in any pain?
Colour?
Items of note around bed?
Hands Comments
Leuconychia
Koilonychia
Clubbing
Palmar creases (anaemia)
Palmar erythema
Spider-naevi
Dupuytren‟s contracture
Pulse rate, rhythm and volume
Hepatic flap

Face/eyes Comments
Jaundice
Anaemia
Mouth ulcers
Dentition
Dehydration
Tongue disorders

Lymph nodes Comments

Occipital
Post-auricular
Pre-auricular
Submandibular
Submental
Anterior and posterior cervical
Supraclavicular (inc. Virchow‟s)
Abdomen - Inspection Comments
Symmetry & Shape (Obvious lumps,
swellings or distension)
Pulsation and peristalsis
Venous distension
Discolouration (Cullen‟s/Grey Turners)

Abdomen - Palpation Comments

Light Palpation - 9 areas
Deep Palpation - 9 areas
Rebound tenderness
Liver
Spleen
Kidneys
Bladder
Aorta

Abdomen – percussion comments

Liver
Spleen
Bladder
Shifting Dullness (if relevant)
Fluid Thrill (if relevant)
Abdomen - Auscultation Comments
Bowel sounds
Aorta
Renal arteries
Liver bruits
Completing the Examination Comments
Hernial orifices/ External genitalia
DRE/ PV
Troisser's sign
Back of abdomen
Bedside investigations
o Temperature
o Urinalysis
THE URINARY SYSTEM
HISTORY
During Phase 1 you will not be taught a separate genitourinary examination but need to consider
relevant parts of the abdominal examination in a patient presenting with
urinary and prostate symptoms. You need to know the common causes of, and be able to fully
explore the following symptoms:
Urinary frequency
Urgency
Dysuria
Haematuria
Urinary incontinence
Polyuria
Anuria
Describe what is meant by each of these symptoms in the table below:
Urinary frequency
Urgency
Dysuria
Haematuria
Urinary Incontinence
Polyuria
Anuria

Use the table below to list common causes of

1. Urinary Incontinence
2. Urinary Frequency and
3. Haematuria

Urinary Incontinence Urinary Incontinence Urinary Incontinence

Think about how you can use the mnemonic SQITARPS to help you explore the symptoms.
For example there are many questions that could be asked about urinary incontinence:

Site
Quality
Intensity - Does it only happen when you get the urge to urinate? Are you
aware of it happening? Can you continue with normal daily activities or do
you need to be near a toilet or use an incontinence pad?
Timing - when did it start? Are you continually leaking urine? Do you leak
only when you do something in particular? Are there any events that coincide
with the onset? i.e. pregnancy, urinary tract infection, constipation, surgery
Aggravating - is there anything which causes you to leak urine? i.e. cough,
laugh, sneeze, lifting heavy objects; has there been any change in your
medication or have you started taking any new tablets? How much do you
drink? Do you drink caffeine and if so, how much?
Relieving - has anything reduced the amount or frequency? i.e. drinking less
fluid, bladder surgery, treatment for infection
Secondary symptoms - Any other urinary symptoms e.g., dysuria, haematuria?
Also consider fever, confusion, rigors.

Lower urinary tract infection and prostatitic enlargement can both present with urinary
frequency. Describe the features of each that may help you to make a diagnosis. Include risk
factors for each condition.

POINT Lower Urinary Tract Prostatic Enlargement

Infection
Features of Presenting
Complaint and
Associated Symptoms
Risk Factors

THE URINARY SYSTEM

EXAMINATION OF THE URINE (URINALYSIS)

You need to know in what situations examination of the urine should be performed and be able
to interpret the findings.
List 5 situations (i.e. in the presence of a particular sign or symptom) when you should
perform urinalysis and give a rationale for your answer.

Sign/Symptom Rationale
Preparation
Urine samples should be collected in a clean dry container and make sure they
are no older than 4 hours at the time of testing.
Urine should be collected midstream.
Always check that the reagent strips are in date before testing,
Wash hands and wear gloves
Inspect Sample
Colour - normal colour of urine can range from colourless to dark yellow, remember to consider
common causes of discolouration, such as bile pigments
Transparency- is the sample clear or cloudy
Odour - abnormal smells such as
Faecal
Sweet
Fruity
Ammonia
Dip the strip in the urine, ensuring that all of the reagent areas have been fully immersed
and remove it immediately
Run edge of strip against the rim of the container to remove excess urine (do not
"flick‟ the excess)
Hold the strip horizontally and compare the test areas closely with the colour chart on the container
label
Read the reagent areas at the specified time on the container label starting with the
shortest time and comment on your findings (colour changes after two minutes are of no diagnostic
value)
Dispose of the test strip in a clinical waste bin
Send the sample to microbiology for microscopy, culture and sensitivity if appropriate

Common Findings
Complete the table below listing possible causes of the presence of each substance in the urine
Subsance Name of Condition Possible Causes

Glucose Glycosuria
Ketones ketonuria
Blood/Erythrocytes Haematuria
Protein Proteinuria
Nitrites Bacteriuria
Leucocytes Pyuria
Bile pigments Bilirubinuria
Haemoglobin Haemoglobinuria
Other Tests to Consider
Culture and sensitivity (swabs from genitalia)
Cystoscopy
Rectal examination of prostate

THE GASTROINTESTINAL AND URINARY SYSTEMS CASE STUDIES

1. Mr Firas, a 61 years old, has attended his GP surgery, complaining of difficulty in

swallowing.
A. What questions would you want to ask to fully explore this?

B. How can you classify dysphagia according to the factors of intermittency and
pain?

C. List the possible causes of dysphagia

D. What questions could you ask to narrow down the list of differentials?

E. On further questioning him, he said he had lost weight in the last few months.
What questions would you ask to verify the significance of his weight loss?

F. What are the signs of weight loss on physical examination?

2. Miss Saja, an 18 years old female, has been vomiting for 24 hours and has had watery
diarrhoea for 12 hours.
A. What questions would you want to ask to fully explore these symptoms?

B. What do you expect her pulse and blood pressure to be?

C. What about her JVP (jugular venous pressure)?

D. What are other signs of dehydration that you would look for in such patient
apart from pulse?

E. If the patient was a 6 months infant, what other signs of dehydration that you
would check for?

F. What do you expect the urine output in this patient to be?

3. Basim, a 42 years old known alcoholic, has come into the surgery for his regular
Thiamine injection. While here, he has mentioned that he feels generally unwell, complaining of
vague abdominal symptoms such as nausea, vomiting and diarrhoea, symptoms he has had 'on
and off' for several years. You examine his abdomen and think that you can palpate the lower
liver edge, but are unsure if it feels normal.
A- When examining the liver edge, what are the features you need to describe?

B- What other symptoms might you expect to find in a patient with chronic liver
disease?

C- What do you expect to find on examining his face?

D- What findings would you seek on examining his nipples and genitalia?

E- What other abdominal signs you expect in this patient?

F- Why patient with chronic liver disease have splenomegaly?

G- Is auscultation of the abdomen beneficial in such patients?

H- 6 months later, he was rushed into the A & E department with recurrent bloody
throw ups and tarry stool. What questions would you want to ask to fully
explore these symptoms?

I- What do these symptoms signify?

J- What are the other sites where blood can be shunted from portal vein to
systemic circulation?

K- Which one of them is clinical seen on inspection the abdomen?

L- What is the definition of portal hypertension?

M- What is the term coffee-ground vomitus means? Can it tell you about the
anatomical site of bleeding?
4.Jasim, a 49 year old, has visited his GP complaining of lower abdominal pain. It began about
six months ago and has been intermittent, although during the last month Tom has had pain
every day. The pain is colicky and comes and goes through the day, with each episode lasting
between 10 minutes and 2 hours, and it varies from mild discomfort (2/10) to severe (8/10).
Paracetamol has no effect on the pain, but it is often relieved by a bowel movement. Tom
has noticed a change in his bowel habits, as when he has the pain, he has more frequent and
looser bowel movements; he also has urgency during or after meals - particularly breakfast.
There is no weight loss, vomiting or bleeding. The GP saw Tom two weeks ago for this
problem and diagnosed Irritable Bowel Syndrome (IBS). Today Tom has confided in you
that he thinks it might actually be bowel cancer, as his father died 9 years ago from this disease.
A. How would you explain the diagnosis of IBS to Tom, remembering to ensure
that you also address his concerns about bowel cancer?

B. What tests would you advise to exclude colon cancer?

C. What is meant by haematochisea? What does it signify about the anatomical

site of bleeding?

D. How is this different from maroon- coloured stool and from melaena?

E. Can upper GI bleeding present with fresh bleeding per rectum?

5- Ali, a 15 years old student, comes to emergency department complaining of right lower
abdominal pain with nausea and vomiting. He is diagnosed with acute appendicitis (AA).
A- What characteristics of abdominal pain that suggest AA?

B- What other important symptoms would you ask about?

C- Why do you think early intervention with AA is important?

D- What do you expect to find on examining his mouth?

E- List Seven abdominal signs seen in patient with AA.

1.
2.
3.
4.
5.
6.
7.

F- What blood test would you send to confirm the diagnosis?

6- Ihsan is a surgical resident who takes multiple pain killers for his backache complains of
severe abdominal pain that is non-responding to paracetamol. On examining him, you finds
him still in bed with pale face and fast shallow breathing. You suspect a perforated viscus?
A- Why do you think he is still in bed? Is it good sign?

B- What do expect to find on palpating his abdomen

C- What is the difference between guarding and rigidity?

D- What is difference between tenderness and rebound tenderness?

E- What do you expect to find on auscultating his abdomen?

F- What do you think the cause of his perforation? By which mechanism?

G- What most likely viscera do expect to perforate in this patient?

H- If you want to confirm your diagnosis, what single radiological test would you
send for? What are the expected findings?
7- Dina is a 42 years old house keeper. She frequently complaining of right upper abdominal
pain. Ultrasound revealed gallstones, but she refuses surgery.
A- What are gallstones?

B- The term "biliary colic" to describe biliary pain is wrong, why?

C- On further questioning, she has right shoulder tip pain. Explain.

D- Could she have jaundice? How?

E- Few weeks later, she came with severe pain, high grade fever, and chills, with
positive Murphy's and Boa's signs, what is meant by these signs? What is
the diagnosis now?

F- What is the difference from Murphy's sign seen in patient with acute
pyelonephritis?

G- What is meant by Saint's triad in patients with gallstones?

8- Thamir is brought to the A & E department complaining of
colicky central abdominal pain with 7 times vomiting. She had a
history of laparotomy for perforated typhoid fever before 2 years.
You suspect acute intestinal obstruction (IO).
A- Use SQITARS to explore his pain.

B- What are characteristics that you would ask about vomiting in this patient?

C- How can you explain the cause of her symptoms

D- What other symptoms would you ask in patient with acute I.O.

E- How can you describe her abdominal scar?

F- What else do expect to find on palpating his abdomin?

G- What do you expect to her on auscultation?

H- How can you confirm your diagnosis radiologically? What are the findings?
9-Sarah is a housewife with 3 children. She came complaining of
generalized itching. On examining her eyes, you find them to be
yellowish.
A- What is wrong with her eyes?

B- What are the types of this sign?

C- On further questioning, she tells you she had pale stools. How
can you
explain this?

D- What do you expect her urine to be? Why?

E- Explain the cause of itching.

F- List the possible causes for her disease?

G- Further questioning revealed significant weight loss, and you
suspect
pancreatic cancer, what clinical signs might be found on
examining the
abdomen, supraclavicular fossae, and superficial veins?

H- What tumour markers are elevated in pancreatic cancer?

10. Maryam is an 18 years old who has attended her GP clinic,

complaining of dysuria, urgency, lower abdominal discomfort and a
mild fever. She denies any loin pain, chills, nausea or vomiting.
Urinalysis results are positive for blood, nitrites and leucocytes.
A- What is meant by the term dysuria?

B- What is meant by the term urgency?

C- What is the likely diagnosis and why?

D- What would be the likely diagnosis if Michaela also had loin

pain, chills, nausea and vomiting, and why?

E- What signs would you find on abdominal examination if she

had such complication?
11- Mr. Saad is complaining of difficulty to pass urine for the past few
weeks. He comes to the A & E department with inability to
pass urine with lower abdominal pain. You suspect acute retention.
A- What other symptoms would you ask for?

B- What do you expect to find on palpating his abdomen?

C- How can differentiate acute from chronic retention?

D- What do you think the cause?

E- What important physical examination would perform to assist in diagnosis?

F- If you suspect prostatic cancer, what blood test would you suggest?