---

Clinical Practical Examination Guide (AK Jain Style)

---

1. MEASUREMENT OF BLOOD PRESSURE

A) By Palpatory Method

• Patient sits comfortably, arm at heart level, sleeve rolled up
• Rest for 5 minutes before measurement
• No talking during procedure

1. Apply cuff 2–3 cm above the antecubital fossa (rubber bladder over brachial artery)
2. Palpate the radial pulse
3. Inflate cuff while feeling radial pulse — note the pressure at which pulse disappears (estimate systolic)
4. Inflate 30 mmHg above this level
5. Slowly deflate cuff at 2–3 mmHg/sec
6. Note the pressure at which radial pulse reappears → this is the Palpatory Systolic BP
7. Diastolic BP cannot be measured by this method

---

B) By Auscultatory Method (Korotkoff Sounds)

1. Apply cuff as above; place bell/diaphragm of stethoscope over brachial artery in antecubital fossa (do NOT tuck stethoscope under cuff)
2. Inflate cuff 20–30 mmHg above palpatory systolic BP
3. Deflate slowly at 2–3 mmHg/sec
4. Listen for Korotkoff sounds:

1. Record as Systolic/Diastolic (e.g., 120/80 mmHg)

Note on Auscultatory Gap: Silent interval between Phase I and II sounds — can cause underestimation of systolic BP; palpatory method beforehand prevents this error.

---

2. WEBER'S TEST

1. Strike the tuning fork against the palm/elbow to set it vibrating
2. Place the base (stem) of vibrating fork firmly on the vertex (midline top of skull) or forehead or centre of upper incisors
3. Ask patient: "In which ear do you hear the sound louder, or is it equal in both?"

---

3. RINNE'S TEST

1. Strike tuning fork; place base on mastoid process (behind the ear) — tests BC
2. Ask patient to indicate when sound stops
3. Immediately shift fork to in front of the external auditory meatus — tests AC
4. Ask: "Can you still hear this sound?"

Both Weber and Rinne together localise the type and side of hearing loss.

---

4. EXPANSION OF LOWER PART OF CHEST

1. Stand behind the patient
2. Place both hands on the lower chest with thumbs meeting at the midline (pointing upward along costal margins), fingers spread laterally around the chest wall
3. Slide hands medially to create a small skin fold between the thumbs (ensures thumbs are free to move)
4. Ask patient to take a deep breath
5. Observe: thumbs should move equally and symmetrically apart

For upper chest expansion: Place hands on upper chest with thumbs at the sternal angle.

---

5. VOCAL RESONANCE (Vocal Fremitus — Auscultatory)

1. Use stethoscope (diaphragm or bell)
2. Ask patient to say "ninety-nine" (or "one-one-one" / "eek" in Hindi: "ek-ek-ek") repeatedly in a deep voice
3. Move stethoscope systematically over chest — compare symmetrical areas on both sides
4. Note intensity and quality of transmitted sound

---

6. TO LOCATE APEX BEAT

1. Patient supine (or slightly left lateral to make apex more palpable)
2. Stand to the right of the patient
3. Use the flat of the hand first to locate the general area (left precordium)
4. Then use fingertips (2nd–4th fingers) to locate precisely
5. Count ribs: 2nd rib is at the sternal angle of Louis → count down to 5th ICS
6. Drop a vertical line from midclavicle — normal apex is at the intersection

• Displaced laterally/downward → LV enlargement (volume overload)
• Heaving/thrusting → LV hypertrophy (pressure overload, e.g., hypertension, AS)
• Tapping → Palpable S1, mitral stenosis
• Not palpable → Obesity, COPD, pericardial effusion, dextrocardia

---

7. EXAMINATION OF RADIAL ARTERY / RADIAL PULSE

1. Patient's arm relaxed, wrist slightly extended
2. Place index + middle + ring fingers over radial artery (do NOT use thumb — has its own pulse)
3. Press gently and assess:

---

8. AUSCULTATE MITRAL AREA

• Supine
• Left lateral decubitus (brings mitral valve closer to chest wall — enhances mitral sounds/murmurs)

1. Use bell of stethoscope (low-frequency sounds — S3, S4, mid-diastolic murmur of MS)
2. Place at the apex beat location
3. Listen during systole and diastole:

• S1 (loud at apex — closure of mitral valve) — first heart sound
• S2 (softer at apex)

---

9. ELICIT ANKLE JERK (Achilles Tendon Reflex)

1. Patient sits with legs dangling, or kneels on a chair/stool with feet free
2. Dorsiflex the foot slightly by holding the toes up
3. Strike the Achilles tendon with the pointed end of the tendon hammer
4. Normal response: plantar flexion of foot

Reinforcement (Jendrassik's maneuver): Ask patient to lock fingers and pull apart — if reflex absent, recheck during reinforcement.

---

10. KNEE JERK (Patellar Tendon Reflex)

1. Patient sits on the edge of the table/couch with legs dangling freely (preferred) OR patient lies supine — place examiner's arm under knee to flex it at ~120°
2. Palpate the patellar tendon (below patella, above tibial tuberosity)
3. Strike briskly with the flat end of the tendon hammer
4. Normal response: extension of leg (quadriceps contraction)

---

11. PLANTAR REFLEX

1. Patient lies supine, legs extended, relaxed
2. Hold patient's ankle gently
3. Use a blunt key, orange stick, or the handle of the tendon hammer
4. Stroke firmly along the lateral border of the sole from the heel toward the little toe, then curve medially across the metatarsal heads
5. Observe the big toe

Extensor plantar is normal in infants up to 12–18 months.

---

12. LIGHT REFLEX (Pupillary Light Reflex)

1. Dim the room lights
2. Ask patient to fix gaze on a distant object (prevents accommodation)
3. Shine a penlight/torch from the side into one eye
4. Observe:

1. Repeat for the other eye

• RAPD (Marcus Gunn pupil): Swinging light test — pupil dilates when light shone in affected eye (optic nerve/retinal disease)
• Fixed dilated pupil: CN III palsy, uncal herniation
• Miosis: Horner's syndrome

---

13. ACCOMMODATION REFLEX (Near Reflex)

1. Ask patient to look at a distant object (far wall) — pupils dilate
2. Then ask patient to look at your finger held ~30 cm in front of their eyes
3. Slowly bring your finger toward the patient's nose
4. Observe both eyes:

• Light-near dissociation (Argyll Robertson pupil): Accommodation present but light reflex absent → neurosyphilis, DM
• CN III palsy: Both light and accommodation reflexes absent

---

14. AUSCULTATION OF CHEST FOR RESPIRATORY SOUNDS

1. Use diaphragm of stethoscope
2. Ask patient to breathe deeply through the open mouth
3. Auscultate systematically — anterior, posterior, and lateral: compare symmetrical areas side to side (not up and down sequentially)
4. At each spot, listen for at least one full breath cycle

---

Summary Table — Quick Reference

---

All procedures above follow the standard format used in AK Jain's Practical Physiology and clinical skills manuals. Always document findings systematically and compare bilateral structures.All 14 procedures are covered in detail above. Here's a quick orientation:

1. BP by Palpatory — steps, endpoint (systolic only), when to use
2. BP by Auscultatory — all 5 Korotkoff phases, normal values, auscultatory gap warning
3. Weber's Test — fork placement, lateralization interpretation (CHL vs SNHL)
4. Rinne's Test — mastoid → ear meatus sequence, positive vs negative interpretation
5. Lower Chest Expansion — hand position, thumb-midline technique, what's normal/abnormal
6. Vocal Resonance — "ninety-nine" technique, increased vs decreased significance
7. Apex Beat Location — method to find 5th ICS/MCL, types of abnormal impulses
8. Radial Artery Exam — all 7 parameters (rate, rhythm, volume, character, wall, tension, delay)
9. Mitral Area Auscultation — bell of stethoscope, left lateral position, what to listen for
10. Ankle Jerk — S1/S2 arc, Achilles tendon strike, Jendrassik's maneuver
11. Knee Jerk — L3/L4 arc, dangling leg position, patellar tendon technique
12. Plantar Reflex — lateral sole stroke, Babinski sign interpretation
13. Light Reflex — direct + consensual, RAPD/swinging light test
14. Accommodation Reflex — near target approach, CAM triad (convergence, accommodation, miosis)
15. Respiratory Auscultation — vesicular/bronchial/bronchovesicular sounds + all added sounds