SpecIfic CVS examination

Inspection(undreess patient to the waist,inspect carefully for 10 scnd),lying 45 degree

Comment on:

1. Chest wall movement with each respiration
2. symmetrically or not
3. chest wall deformity
4. surgical scar
5. silated veins
6. skin discolouration
7. visible pulsation
8. Pecardial bulge
   

Palpation

1. Apex beat( mitral area)
2. Cari apex beat from inferior lateral region,dy biasa beloow nipple skit
3. If x jumpa,roll pateint over left side
4. LOcate apex beat (tunjuk kat examiner kiraan ribs)
5. Access character of :Tapping, Heaving(forceful,sustained,undisplaced impulse "pressure overload due to aortic stenosis/ LV hypertrophy),Thrusting (forceful,unsustainedd,undislace impulse->aortic regurgitation/enlargmnt in mitral),Thrill( palpable murmur)
6. Palpate using palm for: parasternal heave(fro rt ventricular & left atrial hypertrophy),thrill at mitral ,aortic and pulmonary area.suggestd for any stenosis

Auscultation

1. Mitral area->using bell,listen for pan systolic murmurs suggested mitral stenosis
2. using diapghrm->trace up from mitral area to axillae suggested mitral regurgitation
3. Tricuspid area-> serach for pansystolic murmurs( ask patient to breath in ,hold and breath out)
4. Pulmonary area nad aortic area->listen for ejection systolic murmurs for aortic and pulmonary stenosis
   
5. listen kt lt n rt carotid area sugested for ejaction systolic murmur radiate to carotid area,
6. sit the pateint up and listen at 3 area again. This time ask patient to breath in,breath out and hold.

1. Impapable apex beat due tu:
   

• obesity
• pleural & pericardial effusion
• COPD
• Dextocardia(rasa kr sbelah kanan)

General examination

This sample report for General Physical examination

The patient is lying comfortably in supine position propped up to aooroximately 45 degree,He does not look ill,he is concious and alert to time,place,and person.He is not in pain or respiratory distress and his hydrational & nutritional status adequate . There is no muscle wasting ,no grass deformity, and no abnormal movement. There's an intravenous line attached to his right wrist.

Abdominal examination

5 perkara penting yg perlu diberi perhatian sebelum memulakan pemeriksaan terhadap pesakit..Klu nak mudah ingat IPPEC..tgk je patient ingt IPPEC..Ape menda tu?

I-intoduce(kenal kan diri sendiri,examiner,n pesakit dulu)

P-permission(mintak daripada examiner n pesakit)

P-positioning-lying flat dgn 1 pillow

E-exposure adequately( head,neck,upper,n lower limb sikit untuk general examination)

C-comfortable,pastikan pesakit x gelabah..bgi dy tenang n selesa dgn kita

General inspection:

berdiri di hujung katil selama 10 saat..Perhatikan 11 perkara ni betul2 sebelum bgi komen..

• position-patitent lying flat
• comfortable
  
• look-petient nmpk ok ke x
• consciousness n alertness-tnya patient time,place,n person..tgk dy sedar o x(jgn men ckp kt examiner)
• pain-patient nmpk sakit o x
• respiratory distress--nmpk patient kot2 tachypnoea(<20>
• Hydrational status- ada air x tubuh dy..examine tongue,mucous membrane
• nutritional status- obese ka,cachexic ka(bmi ),musle wasting?(tgk dy pnya temporal muscle,deltoid, small musle of hand
• Movement-ada involuntary movement o not@ketaq2 ka

General examination

1.upper limb-examine both site for

• palm-MTC-->moisture,temperature(panas o cool),Colour(pink o pale actually nk tgk samada ada anemia ke x..anemia biasanya berkait lah ngn blood loss due to tumor,ulcer,haemolysis,bleedind disoder,n malabsorbtion b12 n folate x cukup),then tgk jgk palmar erythema
• Finger n nails-cynosis n clubing(klu ada biasanya dy cirrhosis,IBD inflammatory bowel disease,coliec disease,Gi lymphoma),white nail -associated with hypoalbuminemia(cause bymalnutrition,liver disease,malabsorbtion,nephrotic syndrome,malignant,severe burn), kollonychia(spoon-iron dificiency)
• Pulse-rate ,rythm,volume
• forearm &arm -scratches marks,bruising
• Blood pressure

2.Head

• eyes-conjuctive(pink@pale), Sclera-jaundice
• mouth &tounge -tgk cynosis ,ada glossitis( slalunya iron difeciency,megaloblastic anemia), Angular stomatitis(kurang b6,b12 folate) ,Breath fector hepaicus(sweet smell in hepatocellular disease)

3.Chest wall and axillae-

• Spider Naevi , Gynaecomastia (laki jer dowh sbb nye increase in estrogen/androgen ratio-selalu patient yanag ada liver disease,tastis tumour,hyperthyrodism,drug-estrogen,digoxin,spironolactone,cimitidine), ketiak botak@axillary hair loss in Chronic liver disease.

4)lower limb..pitting edaema..press our finger at bony area of ankle in 10 second.

ok..Masuk Ke Specific abdomen exmination exmination

How to start

There are 4 basic steps

• Inspection
• Palpation
• Percussion
• Auscultation

Inspection:

• First skali..tell the patient to expose bju dy from below nipples to mid thigh..tp lebih baik sampai kat atas sedikit pubic hair..klu yg x der pubic hair tu..pndai2 la korang..kena jaga maruah patient jgk..patient 's modesty
• perhatikan selama 10 saat..
• apa nk tgk tu adalah; bentuk perut,ada lump o x..klu ada kena describe dy pnya creteria, tgk ada ape2 pergerakan perut or x mase dy bernafas..tgk jgk position umbilicus inverted or everted(slalunya ascites), tgk surgury scar-(klu ada decribe kat mana pnjang mana sakit ke x,ada timbul x bila coughing) , prominent dilated vein or not (try harvey's sign utk detect direction of flow -nk tgk samada ivc or caput mendusae) , pastu tgk jgk skin colour(bluish-acute pancreatitis,purpleacitis,n pregnancy), tgk jgk peristalsis (klu visible maksud nya ada pyloric stenosis and bowel obstruction), visible pulsation( abdominal aorta anuerysm), then suh patient expose inguinal region..pastu suruh dy batuk then tgk kat bahagian selalunya ada hernia femoral umbilicus,inguinal;;klu ada ..proceed to Hernia examination.

Palpation

bila nk start palpate..start ngn mana2 bahagian..dan palpate clock wise..x nak bgi tertinggal 9 quadrant...setiap quadrant tu, always ask patient for any tenderness..tgk patient's face utk asses sakit ke x. Ada 2 type of palpation..Deep and superficial..superficial ni untuk rasa lembut or solid n utk tenderness..yang deep ni lebih kurang 2 cm ke dalam ..tujuan nye adalah untuk deep tenderness,nak rasa mass and solid vicera.

Klu dapat rasa mass..we must know how to describe..

1.site

2.shape

3.size

4.surface(smooth,regular and irregular)

5.consistancy (soft,cystic,firm @hard)

6.edge

7.Tenderness

8.pulsatile or not

9.mobility

10. Movement with respiration

11.percussion notes

12, fluctuation test& fluid thrill

Macam mana nk beza kan samada mass tu ada kat intara or extra abdominal wall??

haaa..suh patient tu lying flat..pastu suh dy angakt extended leg..klu mass kat amdominal wall tu hilang or jadi makin kecil..indicate that tke mass within abdominal wall..klu intraabdominal mass dy akan bergerakvertivally with respiration.....

Then , we Liver palpation.

1. ask patient to breath in and out slowly
2. Start palpate from RIF
   
3. Confirm lower border and upper border by Percussion
4. measure liver span
5. If hepatomegaly present, Describe menda2 ni
   

• size,consistancy( soft,firm,hard)
• surface (smootg/nodular) n margin
• Tenderness (tender for heptitis patient,hepatocellular ca,hepatic abscess)

Spleen pulpation

1. Start from Iliac fossae toward the upper quadrat with each respiration
2. sampai je kat rib cage margin, press firmly
3. if not palpabe, pusing patient to right side adn repaeat palpation.
4. time patient pusing, percuss kat area 9,10 11 intercosatal space at mid-axillary line(Traube space)

Then,ballot the kidney,

1. Ballot kiri n kanan

Proceed with shifting dullness n fluid thrill..(do if dullness present on percussion)

1.Percuss start kt umbilicus toward left site.
2.Percuss sampai kt dull area,pastu pusing patient to right (jari kita stay kt tmpt dull)..tggu 10 saat,then percuss balik.if resonant..suspected ascitis

Auscultation

Bowel Sound
1. place statescop to the lower right of umbilicus
2. If presnt (komen insrease or decrease)
3.KOMEN ABSENT if xdpt dgr dlam 2 minit

Renal Bruits
1. Place statescop at upper part of right and left umbilicus

Then finish examination with doing external genitalia and rectal examination.

Contoh KOMENTERI:

The abdomen is soft and non tender,there was no mass palpable on deep palpation, the liver palpable 3 cm below costal mardin,it was firm,smooth in surface,well define margin, non tender, and non pulsatile.,there was no bruit heard, the kidney and spleen not palpable, Shifting dullness was negative, bowel sound present with normal intensity. There was no renal bruits.

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