2017

 Most of the information gathered is from Bates and from what is taught during the
ward sessions.
 Please take note that this is just a guide and Please DO NOT memorize this,
understand and know this by heart. The proctor wouldn’t be pleased with you
reciting everything, believe me they will be pissed. Alam nila kung sino yung
nagmemorize lang. Alam at master na nila ya kaya make sure you know what you are
doing and saying. Kapag may nakalimutan ka try mo balikan yung iba pumapayag.
 Good luck and God bless Batch 2017. #OperationVneck.

 INTRODUCE yourself
 ASK the patient’s name
 EXPLAIN the procedure to the patient. Ask consent.
 Ask the patient to REMOVE HIS SHIRT

o “Hi, Good Morning po ako po si Dra. Kim Madrid ako po yung student doctor
na mageexamine po sa inyo ngayon ng Chest and Lungs. Okay lang po ba?”

o “Okay lang po ba kung tanggalin natin ang pangitaas niyo na damit at umupo
po tayo ng matuwid para maexamine kop o kayo. Salamat po”

REMINDER:
 Examiner’s position is on the RIGHT SIDE

1. Inspect for the skin, subcutaneous blood vessels and muscle development and
for any visible contractions of accessory muscles of respiration

SAMPLE REPORT: Skin is brown in color, warm to touch. There is no visible

subcutaneous blood vessels with normal muscle development. There are no
visible contractions of accessory muscles of respiration.

If asked: Accessory muscles of inspiration includes:

 Sternocleidomastoid
 Scalene anterior, medius and posterior
 Pectoralis major and minor

]
 3. Inspect for the bony thorax shape, symmetry and gross deformities. Inspect also the
Anteroposterior (AP) Diameter.

SAMPLE REPORT: Bony thorax is elliptical in shape, symmetric with no gross

deformities noted. AP diameter is 1/3 or 2/3 of transverse diameter.

3. Check the respiratory rate for 1 full minute (Strictly 1 minute). Assess the rhythm.
Inspect thorax for any intercoastal retractions/bulging, widening of ICS and lagging.
Note Rate, Depth, and pattern of respiration.

SAMPLE REPORT: The Respiratory rate is _____ cpm with normal depth and rhythm;
Inspiration is longer than expiration with effortless breathing, symmetric chest
expansion no bulging and widening of the ICS without chest lagging.

1. Palpate for any masses and tenderness (Includes skin, muscles, cartilages, scapula and
spine)

SAMPLE REPORT: There are no tenderness and masses noted upon palpation

2. Palpate equal chest expansion. Place your thumbs at about the level of 10th ribs, with
your fingers loosely grasping and parallel to the rib cage.

INSTRUCT THE PATIENT:

“Hinga po kayo ng
malalim”
Watch the distance
between your thumbs as
they move apart during
inspiration, and feel for the
range of symmetry of the
rib cage as it expands and
contracts.

SAMPLE REPORT:Patient has symmetrical lung expansion.

3. Feel for TACTILE FREMITUS. Use either the bony part of the palm at the base of the
finger or the ulnar surface of the hand

SAMPLE REPORT: Equal tactile fremitus on both lung fields.

]
 or

LOCATIONS FOR FEELING TACTILE FREMITUS

1. Percuss one side of the chest and then the other at each level in a ladderlike pattern.
AREAS OF PERCUSSION

SAMPLE REPORT: Resonant on all lung fields except on the 3-5 th LICS location of the heart
and to 7th RICS MCL At the back: resonant on all lung fields.
]
 AREAS OF AUSCULTATION

1. AUSCULTATE on the different auscultatory areas note FOR BREATH SOUNDS. Instruct the
patient to inhale and exhale on each site. REMEMBER to NEVER remove your
stethoscope while the patient is still inhaling)

SAMPLE REPORT: Vesicular breath sounds on all lung fields.

2. AUSCULTATE on the different auscultatory areas note for BRONCHOPONY. Instruct the
patient to say tres-tres every time you place the stethoscopes on auscultatory areas. “Sir
sabihin niyo po yung salitang tres-tres sa tuwing nilalagay ko yung stethoscope ko sa
iba’t ibang parte ng dibdib niyo po”

SAMPLE REPORT: Sounds are muffled negative for bronchopony.

3. Ask the patient to say “E” every time you place the stethoscope on an auscultatory area. You
will normally here a muffled long “E” sound. When the sound becomes “AY”, there is
EGOPHONY.

SAMPLE REPORT: Sounds are muffled with a long “E” sound, negative for egophony

4. Ask the patient to whisper “TRES-TRES” every time you place the stethoscope on an
auscultatory area. Normally, the whispered voice sound is faint and indistinct if heard. A
louder whispered voice sound is called WHISPERED PECTORILOQUY.

SAMPLE REPORT: Sounds are indistinct and cannot be clearly heard, negative for whispered
pectoriloquy

]
 1. Check for BULGING OR DEPRESSION of the thorax. CHECK for the PRECORDIAL
PULSATIONS by Using a penlight inspect for visible pulsation in a supine position

SAMPLE REPORT: There is no bulging or depression of the thorax with adynamic

precordium, no visible pulsations upon tangential lighting in supine position

2. NECK
a. ELEVATE THE HEAD OF THE PATIENT BY 30⁰ (In Practicals, just fold the pillow
into half to elevate the head). Turn the head of the patient away from you. Inspect
and palpate the carotid pulse.

SAMPLE REPORT: Carotid pulse is palpable strong and bounding

b. INSPECT for NECK VEIN DISTENTION

SAMPLE REPORT: No neck vein distention

c. CHECK FOR Jugular vein pressure. Place your ruler on the sternal angle and line
it up with another ruler or straight object at an exact angle to the ruler. Read
the vertical distance on the ruler. Round your measurement off.

NOTE: Before you perform this procedure mention that JVP is usually check when
there is presence of neck vein distention and you will perform this for
demonstration purposes only.

SAMPLE REPORT: Jugular venous pressure is ____ cm H20 (Add 5, normal JVP is 3-4 from
Sternal angle of Louis or 8-9 from the right atrium.

]
 1. PALPATE for POINT OF MAXIMAL IMPULSE (The point of maximal impulse (PMI) is
where the cardiac impulse can be best palpated on the chest wall. Frequently, this is at the
5th intercostal space at the midclavicular line.)

a. Locate the clavicle

b. Locate the 2nd interspace, proceed until you reach the 5th interspace
c. Place the palm of your hand in the fifth intercostal space and the left
midclavicular line (PMI is normally within 10 cm ofthe sternum on the left side).
d. Note the location of the PMI.
e. Note the size of the PMI (PMI is normally 2-3 cm in diameter).

**Note: You should mention the boundaries in order for the proctor to understand what you’re doing.

SAMPLE REPORT: The apex beat is at 5th Left intercoastal space midclavicular line

2. PALPATE FOR:
a. LIFTS & HEAVES
- sustained impulses produced by an enlarged right or left ventricle or atrium
- use FINGER PADS
- sign of left ventricular hypertrophy.

b. THRILLS
- Use BASE OF PALM
- Palpable murmur. Thrill feels like a vibration

Feel for this in a Z pattern staring from the apex beat going to the left parasternal line up to the erbs
point, then to the pulmonic area and going to the right to the aortic area.

SAMPLE REPORT: No palpable thrills, heaves and lifts noted.

]
  INCHING/Z technique
 Use bell and diaphragm of the stethoscope
 POSITION OF THE PATIENT: Lateral or Leaning forward

1. AUSCULTATE the HEART RATE AT THE APEX, assess for rate and rhythm of the heart.

SAMPLE REPORT: Heart rate is ___ bpm for 1 full minute (STRICTLY) with normal rate and
regular rhythm.
 Normal rate: 60-100 bm
 GREATER than 100 bpm – TACHYCARDIA
 LESS than 60 bpm – BRADYCARDIA

]
 **FOR A SYNCHRONIZE AUSCULTATION, FOLLOW THE Z TECHNIQUE.

SAMPLE REPORT:S1 is loudest at the APEX and S2 is loudest at the BASE

]
 2. Place the patient in LEFT LATERAL DECUBITUS POSITION bringing the left
ventricle close to the chest wall, PLACE THE BELL of the stethoscope and lightly
place it in the apex

SAMPLE REPORT: : No of S3 and S4, no extra heart sounds heard.

3. ASSESSING PULMONIC MUMURS, AORTIC MURMUR AND PHYSIOLOGIC SPLITTING

Ask the patient to sit up, leaning forward, exhale completely and stop breathing in
expiration. PLACE THE DIAPHRAGM OF the stethoscope. Place the stethoscope along the
LEFT STERNAL BORDER and at the APEX, pausing periodically so the patient may
breathe. Ask patient to inhale exhale then hold “Hinga malalim, exhale then stop)

SAMPLE REPORT: No aortic and pulmonic murmurs heard. There is a positive/negative

physiologic splitting.
]
 4. CHECK FOR BRUIT – after checking the bruit check for peripheral pulse. Let the
patient lie down in supine position, turn the head of the patient away from
examiner. Use the bell of the stethoscope in the carotid artery.

SAMPLE REPORT: There is no bruit heard in the carotid artery (Note: bruit + aortic
murmur= aortic stenosis, pulmonary murmurs does not produce bruit in carotid
artery)

5. CHECK FOR PERIPHERAL PULSES

PALPATE:
a. Carotid pulse

SAMPLE REPORT:Carotid pulse palpable strong and bounding.

b. Brachial
c. Radial
d. Femoral (Usually not done. Ask the proctor if you need to check the
femoral artery. If they say “Ikaw bahala” DO IT.
e. Popliteal (one at a time)
f. Dorsalis pedis

SAMPLE REPORT: (________________) is pulse palpable strong and

bilaterally equal o Dorsalis pedis- maybe present or absent.

]
]
  INTRODUCE yourself
 ASK the patient’s name
 EXPLAIN the procedure to the patient. Ask consent.

o “Hi, Good Morning po ako po si Dra. Kim Madrid ako po yung student doctor
na mageexamine po sa inyo ngayon ng HEENT. Okay lang po ba?
Magsisimula na po ako” – Sample only don’t memorize much better if you act
like a real doctor in front of the patient.

1. ASSESS for hair color, quantity, distribution, texture, condition of scalp.

PALPATE size, shape, symmetry, deformities, masses and tenderness. CHECK
the TEMPORAL ARTERY.

SAMPLE REPORT: The hair is black in color, abundant, well distributed, smooth / dry
texture, Scalp is slightly movable along with the cranium, no lesions, no parasites (lice)
The cranium is normocephalic, symmetrical, and has no deformities. No tenderness no
masses. Temporal arteries are NOT VISIBLE BUT PALPABLE with STRONG/WEAK
pulsation.

1. ASSESS for symmetry, skin color, texture and lesions.

SAMPLE REPORT: The face is symmetrical, skin is brown in color smooth with no
lesions (If with pimples or scared pimple indicate if it is papular lesion or round
scar)

2. ASSESS for facies/ facial expression by ASKING THE PATIENT TO SMILE OR

FROWN. “Sir, pwede po bang ngumiti po kayo, then sumimangot po” CHECK Facial
movements.

SAMPLE REPORT: There is no abnormal facies/facial expression and no

involuntary movement noted.

]
Start from the hair at the top (eyebrow) going down (eyelash). Next is Eyelid going down to
the periorbital area going to the eye ball.

1. EYEBROW. Note color and distribution. EYE LASH. Note color and characteristics.

SAMPLE REPORT: Eyebrows are black, well distributed. Eyelash is black, short and
present in both upper and lower eyelids.

2. EYELIDS. MEASURE the WIDTH OF PALPEBRAL FISSURE (Measure using ruler

(Measurement of the eyes from lateral cantus to medial cantus or vice versa), ptosis,
retraction, relationship of upper and lower eye lid to the limbus (Exopthalmos,
enopthalmos, lid lag if + exopthalmos) “Sir tingin nga po kayo sa daliri ko then
sundan niyo po ng hindi gumagalaw yung ulo niyo po)

SAMPLE REPORT: Palpebral fissure is about ______cm in diameter. Eye lid has no
lesion no edema and negative for lid lag negative for exopthamos and enopthalmos.

3. PERIORBITAL AREA. NOTE for any sunken, swelling and hematoma. EVALUATE
EYE BALL TENSION by palpation.

SAMPLE REPORT: Periorbital area are not sunken, swelling and no hematoma. Upon
palpation no tenderness of the eyeball was noted.

]
OUT GOING IN

4. CONJUNCTIVA & SCLERA

SAMPLE REPORT: Conjunctiva is pinkish/pale in color, no swelling and hematoma.

Sclera is white in color and no lesions noted.

5. CORNEA. USING A PENLIGHT with oblique lighting, inspect the cornea of each eye
for opacities and note any opacities in the lens that may be visible through the pupil.

IRIS. At the same time, inspect each iris. The markings should be clearly defined. With
your light shining directly from the temporal side, look for a crescentic shadow on the
medial side of the iris.

SAMPLE REPORT: Cornea is transparent, no opacities, no ulcers, no foreign body .

Iris is round and black/brown in color.

6. PUPIL. Measure the pupil in diameter. Next check if it is reacting to light (Constrict
with light and dilates without light) and Accommodation (Dilate when object is near
pupil constricts when object is far it dilate)

Ask the patient to look into the distance, and shine a bright light obliquely into each
pupil in turn. (Both the distant gaze and the oblique lighting help to prevent a near
reaction.) Look for:
 The direct reaction (pupillary constriction in the same eye)
 The consensual reaction (pupillary constriction in the opposite eye)
 Accommodation \

7. LENS. Lens opacity can be seen with the previous exam you did in pupils.

SAMPLE REPORT: Pupils symmetrical, about ____mm in diameter upon constriction,

round and reactive to light and accommodation. Positive Direct and Consensual light
reflex. Both lens are transparent and no opacity noted.

]
 8. VISUAL ACUITY. Reading material or a news paper ask the patient to read a the
smallest letter in about 12 inches or 1 foot length.

SAMPLE REPORT: The patient was able to read the smallest font in a news paper
print at a distance of 1 foot.

9. VISUAL FIELD. Confrontation test. Ask the patient to look with both eyes into your
eyes. While you return the patient’s gaze, place your hands about 2 feet apart, lateral
to the patient’s ears. (Sir/Maam Tingin po kayo sa mga mata ko then turo niyo po
kung san niyo po nakikita yung kamay ko po)

SAMPLE REPORT: No gross defects in visual field

1. Inspect the External ear. ASSESS size, shape, symmetry, deformity or any lesions

SAMPLE REPORT: The patient has normal set of ears. symmetrical no deformity no
lesions

2. PALPATE for tenderness over the auricles and mastoid. (Move the pinna and
tragus if there is pain + TUG TEST = + OTITIS EXTERNA)

SAMPLE REPORT: No tenderness noted on the pinna and mastoid area

]
 3. By using the PENLIGHT. ASSESS the EXTERNAL AUDITORY CANAL. Assess
patency, color of walls discharge and foreign body.

SAMPLE REPORT: External auditory canal is patent, walls are pinkish in color, no
discharges and no foreign bodies.

4. CHECK the TYMPANIC MEMBRANE using the otoscope. (OPTIONAL)

SAMPLE REPORT: Tympanic membrane is pearly white in color with good cone of
light, no bulging, no retraction, and no perforation.

5. HEARING TEST. Standing 1 or 2 feet away, exhale fully (so as to minimize the
intensity of your voice) and whisper softly toward the unoccluded ear. “Sir, pwede
takpan niyo po yung isang tenga niyo po, then bumulong ka ng any word that is
understandable to the patient”

SAMPLE REPORT: Patient can hear soft spoken voice clearly on both ears.

]
 1. ASSESS for size and shape. CHECK movement of ala nasi.

SAMPLE REPORT: Nose is symmetrical and blunt. There is no presence of alar flaring.

2. Examine vestibule for patency, mucosa, secretions, bleeding points, nasal septum
(Position and perforation. close one nostril of the patient then ask the patient to
sneeze, do this in the other side)

SAMPLE REPORT: Nasal vestibule is patent pinking in color with no secretions and
no bleeding, nasal septum is straight at the midline and no perforation. Turbinates are
_____ in color no edema no swelling no secretions.

3. ANTERIOR RHINOSCOPY.
a. Examine patency
b. Secretion of nares
c. Septum - color, lesion, deviation
d. Turbinates – color, vascularity, edema, swelling, secretions

TILT THE PATIENT’S HEAD BACK

a bit and insert the speculum gently
into the vestibule of each nostril,
avoiding contact with the sensitive
nasal septum. Hold the otoscope
handle to one side to avoid the
patient’s chin and improve your
mobility.

4. Check for PARANSAL SINUS. (Frontal & Maxillary) Palpate for tenderness &
transullimination. (Press up on the frontal sinuses from under the bony brows,
avoiding pressure on the eyes. Then press up on the maxillary sinuses.)

]
REPORT: There is no tenderness of the paranasal sinuses upon palpation and there is no
clouding of the paranasal sinuses upon transillumination test

INSPECT :
1. LIPS

SAMPLE REPORT: Lips are pink in color, symmetrical, dry, with no lesion.

2. BUCCAL MUCOSA

SAMPLE REPORT: Buccal mucosa is Pinkish and moist, no lesions no swelling.

]
 3. TONGUE (Instruct the patient to protrude tongue move upwards downwards, laterally
and retract )
SAMPLE REPORT: Tongue is pink in color no lesion no hypertrophy and atrophy, Tongue is in
the midline in position upon protrusion and retraction, can move without difficulty.

4. TEETH
SAMPLE REPORT: Complete set of Teeth, no dental carries, no malocclusion.

5. GINGIVA
SAMPLE REPORT: Gingiva are pinkish, no bleeding, no gingival recession, no hypertrophy or
atrophy.

6. PALATE:
SAMPLE REPORT: Palate is pinkish with no lesions has symmetrical elevations uvula is in
midline.

7. TONSILS
SAMPLE REPORT: Tonsils are small and pink, no enlargement, no secretion, no exudates

8. PHARYNGEAL WALL
SAMPLE REPORT: Posterior pharyngeal wall is pinkish with no lesions, no swelling, no
exudates.

1. Describe SKIN
SAMPLE REPORT: Skin is brown in color

2. Architecture, Palpate for tenderness and muscle tone

SAMPLE REPORT: No deformity, neck is symmetrical, Trapezius and sternocleidomastoid are
well developed.
]
 3. Range of motion. Ask the patient to flex, extend, lateral bending, neck rotation.
SAMPLE REPORT: No deviation of movement patient was able do perform ROM without
difficulty.

4. Trachea position and deviation page.

SAMPLE REPORT: Trachea is in the midline

INSPECT THE TRACHEA for any

deviation from its usual midline
position. Then feel for any
deviation. Place your finger along
one side of the trachea and note the
space between it and the
sternomastoid. Compare it with the
other side. The spaces should be
symmetric.

5. Inspect for the thyroid. Ask the patient to extend the neck again and swallow. Watch for
upward movement of the thyroid gland, noting its contour and symmetry. The thyroid
cartilage, the cricoid cartilage, and the thyroid gland all rise with swallowing and then
fall to their resting positions. “Sir, tingala lang po tayo and lumunok po kayo”

SAMPLE REPORT: Thyroid gland moves with deglutition.

]
 6. Palpation of the thyroid gland.

SAMPLE REPORT: Thyroid gland is not visible but palpable with no tenderness.

7. Palpate the lymph node. Using the pads of your index and middle fingers, move the skin
over the underlying tissues in each area. The patient should be relaxed, with neck flexed.
slightly forward and, if needed, slightly toward the side being examine.

SAMPLE REPORT: There is no submental, submandibular, preauricular, posterior auricular, occipital,

superficial cervical, deep cervical, posterior cervical, and supraclavicular lymph adenopathy. There is
a tonsillar lymphadenopathy.