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Ростовский Государственный Медицинский Университет

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Медицина общая

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Книга_3067_Библиотеки_им_академика_М_И_Перельмана

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Plaque: plateau-like

Nodule: marble-like lesion

Primary Skin Lesions

Flat Nonpalpable

• Macule: <1 cm

• Patch: >1 cm

Palpable Solid Elevations

• Papule: <0.5 cm

• Plaque: >0.5 cm

• Nodule: >0.5 cm in both diameter and

depth

• Cyst: encapsulated nodule ﬁlled with

expressible ﬂuid

1 cm

0.5 cm

https://t.me/med1917

Primary Skin Lesions Continued

• Scale: Visible thickened stratum

corneum; dry and usually whitish

Palpable Fluid-Filled Cavities

• Vesicle: <0.5 cm blister ﬁlled with clear

ﬂuid

• Bulla: >0.5 cm blister ﬁlled with clear

ﬂuid

• Pustule: vesicle ﬁlled with cloudy or

purulent material

Vascular Lesions

• Telangiectasis: superﬁcial blood vessels

0.5 cm

https://t.me/med1917

Primary Skin Lesions Continued

• Purpura: bleeding under the skin

• Petechia: <2 mm, pinpoint,

red-purple, nonblanching macule

(clinically relevant when multiple

petechiae are present)

1 cm

• Ecchymosis: larger bruiselike

purpuric lesions

1 cm

Melanoma Screening

• Asymmetry: one half of the lesion does

not mirror the other half

• Border: irregular, shaggy, or indistinct

• Color: variegated, nonuniform pigment,

and varied shading or hues

• Diameter: >6 mm

• Evolving: notable change over time;

ulceration and bleeding are late signs

6 mm

Telangiectasia: can be

visible with the naked eye

ABCDEs of Melanoma

• Asymmetry

• Border

• Color

• Diameter

• Evolving

The “ugly duckling” lesion:

one that strikes the examiner

as unlike the others

https://t.me/med1917

8 Neurological

Mental Status Exam

• Appearance, behavior, attitude, level of

consciousness, mood

• Orientation (×4): person, place, time,

and situation

• Insight and judgment: “What do you do

with a stamped envelope?”

• Attention: “Spell ‘world.’ Now spell it

backwards.”

• Memory: “Say and repeat three words.”

Proceed with exam and request words

again in 5 minutes.

• Intellectual: “Name ﬁve of the largest

cities. How are an apple and an orange

similar?”

Cranial Nerves

CN I Test smell

CN II Visual acuity; visual ﬁelds; pupils

equal, round, react to light,

accommodation (PERRLA); swing test

CN III, IV, VI Extra-ocular motions (EOM)

CN V Face sensation (six spots), motor

(clench teeth)

CN VII Raise eyebrows, close eyes and

hold, smile, puff out cheeks

CN VIII Rub ﬁngers by ears (with

patient’s eyes closed)

CN IX, X Say, “ahh” (and observe palatal

elevation). Say “kah-kah-kah...la-la-la...

gah-gah-gah.”

CN XI Turn face left/right against

resistance. Shrug shoulders

CN XII Stick tongue out (observe), move it

side to side

MINI COG

• Oriented (×4): name,

location, date, and

situation

• Memory: “Say and

remember three words.”

• Draw a clock with a

speciﬁc time

• After ﬁve minutes, ask the

patient, “What were the

three words I asked you to

remember?”

CN II and III: both PERRLA

and swing test require

functioning cranial nerves II

and III.

Visual Acuity: test visual

acuity while patient is wearing

their glasses or contact lens.

https://t.me/med1917

Motor Exam (Basic)

1. Shoulder: ABduct

2. Elbow: extend/ﬂex

3. Wrist: extend/ﬂex

4. Finger: ABduct/ADduct

5. Thumb: opposition

6. Hand grip

7. Hip: extend/ﬂex/ABduct/ADduct

8. Knee: extend/ﬂex

9. Ankle: dorsiﬂex/plantarﬂex

10. Great toe: extend/ﬂex

Sensory Exam

1. Light touch

2. Pinprick

3. Vibration

4. Proprioception

5. Graphesthesia

6. Stereognosis

7. Tactile extinction

Deep Tendon Reﬂexes

1. Biceps reﬂex

2. Brachioradialis reﬂex

3. Triceps reﬂex

4. Patellar reﬂex

5. Achilles tendon/ankle reﬂex

6. Plantar response (Babinski)

Cerebellar Exam

1. Finger to nose

2. Rapid alternating movement

3. Heel to shin

4. Gait (ordinary/tandem)

5. Romberg + pronator drift

Fan ﬁngers to ABduct

Vibration: place tuning fork on

pads of ﬁnger and toes

Test Light Touch and

Pinprick: on one region of

bilateral upper arms, forearms,

hands, ﬁngers, trunk, upper

legs, lower legs, feet, toes

Grade Deep Tendon

Reﬂexes 0-4

• 0 = No response

• 1+ = Slight

• 2+ = Normal

• 3+ = Very brisk

• 4+ = Clonus: repeating

reﬂex

1+, 2+, or 3+ can be normal

Remember to check EOM,

saccade, and nystagmus

Romberg

• Have patient stand with

feet together when eyes

are closed

• Remember Romberg tests

proprioception. Gait tests

more than cerebellar

function

https://t.me/med1917

9 Dermatomes

T10

T11

T12

S2, 3

Root, Motor, Sensation, Reﬂex

• C5: shoulder abduction, sensation to

lateral arm, biceps reﬂex

• C6: wrist extension, thumb and index

ﬁnger sensation, brachioradialis reﬂex

• C7: wrist ﬂexion, middle ﬁnger

sensation, triceps reﬂex

• C8: ﬁnger ﬂexion, ring and small ﬁnger

sensation

• T1: ﬁnger adduction/abduction, medial

arm sensation

C5: clavicles

C5, C6: lateral sides of upper

limbs

C8, T1: medial sides of upper

limbs

C6: digit 1 (thumb)

C6, C7, C8: hand

C8: digits 4 and 5 (ring and

little ﬁngers)

T4: level of nipples

T10: level of umbilicus

L1: inguinal region

Mnemonic for Deep Tendon

Reﬂexes

• One, two, buckle my shoe

(S1, S3 ankle)

• Three, four, kick the door

(L3, L4 knee)

• Five, six, pick up sticks

(C5 biceps and C6

brachioradialis)

• Seven, eight, shut the gate

(C7, C8 triceps)

https://t.me/med1917

L1, L2, L3, L4: anterior and

inner surfaces of lower

limbs

L4, L5, S1: foot

L4: medial side digit I (great

toe)

L5, S1, S2: lateral and

posterior surfaces of lower

limbs

S1: lateral margin of foot and

digit V (little toe)

S2, S3, S4: perineum

T10

T11

T12

S1S2

Root, Motor, Sensation, Reﬂex Continued

• L1: hip ﬂexion, sensation below inguinal

ligament

• L2: hip adduction, mid-thigh sensation

• L3: knee extension, lower thigh

sensation

• L4: foot dorsiﬂexion/inversion, medial

leg/foot sensation, patellar reﬂex

• L5: toe extension, lateral leg/dorsal foot

sensation

• S1: foot plantar ﬂexion/eversion, lateral

foot sensation, Achilles reﬂex

https://t.me/med1917

Hepatojugular Reﬂux: Push

upward on liver. Look to see

elevation of JVP for more than

a few seconds.

10 Vascular

Venous

• Jugular venous pressure (JVP)

• Hepatojugular reﬂux

• External jugular vein

Palpate Pulses

• Carotid

• Listen for bruits with diaphragm

• Brachial

• Radial

• Femoral

• Popliteal

• Posterior tibialis

• Dorsalis pedis

Edema

• Palpate

• Dorsum of the foot

• Behind medial malleolus

• Shins bilaterally

• If one leg is larger than the other,

measure

• Smallest circumference above the

ankle

• Largest circumference at the calf

• At mid-thigh with knee extended

• Abnormal if there is a difference

• >1 cm above the ankle

• >2 cm at the calf

Nonpitting

edema

Pitting

edema

Examine rate, rhythm, and

symmetry

Grade pulses 0 to 2+

With edema, note if

• Bilateral or unilateral

• Pitting or nonpitting

• Tenderness

• Skin changes

Compare one side to the other

https://t.me/med1917

11 Cardiac

Heart

• Inspect

• Palpate

• Heaves and thrills

• Point of maximum impulse (PMI)

• Auscultate

• Six areas with bell and diaphragm

• Patient in left lateral decubitus—

auscultate with bell at 5th

midclavicular interspace or over PMI

• Listen in left 3rd and 4th interspaces

with diaphragm and bell with patient

leaning forward

Midclavicular

line

Midclavicular

line

Core cardiac exam:

auscultate 4 places on skin

(aortic area, pulmonic area,

tricuspid area, and mitral area

[APTM]); each place 2 cardiac

cycles in length

Auscultation on female

patients: acquire better

access to the apex of heart by

asking the patient to lift up

her left breast with her left

hand

https://t.me/med1917

(medial

basal)

(superior,

lower lobe)

(posterior)

(anterior

basal

)

(lateral

basal

)

(posterior

basal)

(apical)

(anterior)

(lateral)

(medial)

12 Pulmonary

General Inspection

• Work of breathing

• Cyanosis

• Clubbing

Posterior

• Inspection

• Palpation: eight areas (four each side)

• Chest expansion

• Normal: >2 cm

• Tactile fremitus: “99” (eight areas)

• Percussion: 14 areas (seven each side)

• Diaphragmatic descent (normal:

3–5.5 cm)

• Auscultation: 14 areas (seven on each side)

Remember to ladder

In areas of abnormality test for

• Bronchophony

• Say, “99”

• Abnormal: louder

indicates consolidation

• Egophony

• Say, “e”

• Abnormal: e → a

change

• Whispered pectoriloquy

• Whisper, “99”

• Abnormal: louder

https://t.me/med1917

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