Professional Documents
Culture Documents
Exam
Inspection
Colour,
Breathlessness,
Distress,
Marfan’s,
BMI,
Breathlessness,
Sweating
Hands
Clubbing,
Colour,
Cap.
Refill,
Splinter
Haemorrhages,
Temp.,
Tremor,
xanthelasma,
osler’s
nodes,
Janeway
lesions.
Wrist
Radial
Pulse
(rate,
rhythm,
character),
radial-‐radial/femoral
delays.
Elbow
Brachial
Pulse,
Waterhammer
Pulse.
Ask
for
BP
Eyes
Pallor,
arcus,
Kaiser
flescher
rings,
xanthelasma,
retinopathy
Tongue
Central
cyanosis
and
tooth
decay.
Neck
Carotid
pulse,
bruits
(aortic
stenosis),
JVP
Chest
look
Deformity,
Scars
Chest
/
Heart
Feel
Apex
beat,
Heaves,
Thrills,
Auscultate
4
valve
positions
(mitral,
tricuspid,
pulmonary,
aortic).
Lean
Pt
on
Left
Auscultate
apex
and
axilla
for
mitral
regurge
Sit
pt
forward
Auscultate
(diaphragm)
for
aortic
stenosis
Auscultate
lung
bases
(pul.
oedema)
Abdo
AAA
Legs
Femoral
/
popliteal
/
post
tibial
/
dorsalis
pedis
pulses
Ulcers,
Ankle
oedema
Extras
Fundoscopy,
BP,
urine
dipstick,
Temp.
Respiratory
Exam
Inspection
Cough,
BMI,
Fever,
Distress,
Drugs
Hands
Clubbing,
colour,
cap.
Refill,
asterixis,
thenar
wastage,
tobacco
staining,
tremor
Wrist
Radial
Pulse
(rate,
rhythm,
character)
Respiratory
rate
Ask
for
BP,
mention
pulsus
paradoxus
Eyes
Pallor,
Horner’s
Synd.
Tongue
Central
cyanosis
Neck
JVP,
Lymphadenopathy,
Accessory
muscle
use
Tracheal
Deviates
to
side
of
collapse,
away
from
tension
pneumothorax
deviation
&
tug
Chest
Scars
Surgery?
Deformity
Pectus
excavatum?
Barrel
chest?
(AP
=
lateral)
Expansion
Equal
R/L?
↓
=
PE,
consolidation,
fibrosis,
pneumothorax
or
collapse
Percussion
↑
in
pneumothorax,
↓
in
all
else
TVF
↑
TVF
=
consolidation,
fibrosis,
top
of
effusion
Auscultation
Crackle→oedema
or
fibrosis
(fine)
or
bronchiectasis/pneumonia
(coarse).
Rub→
pleura
infarct
/
inflammation
(pneumonia)
Wheeze
→
obstruction.
Bronchial
Breathing→
consolidation,
fibrosis,
top
of
effusion.
Breathing
sound
↓
=
consolidation,
obesity,
over
Pleural
Effusion,
pneumothorax.
Ankle
Oedema
Extras
Peak
flow,
O2
sats,
spirometry,
Temp.,
sputum
pot
Abdominal
Exam
Inspection
Drugs,
regimen,
hydration,
musculature,
fever,
SOB,
jaundice,
distress
Hands
Clubbing,
koilonychia
(↓
Fe2+
anaemia),
leukonychia,
palmar
erythema,
Dupuytren’s
contracture,
asterixis,
Spider
naevi
(all
else
is
Liver
failure)
Face
Spider
naevi,
Jaundice,
parotid
swelling
(ETOH)
Eye
Jaundice,
pallor
Mouth
Angular
stomatitis
(thrush,
↓
Fe2+),
glossitis
(↓
Fe/folate/B12),
ulcers
(Crohn’s),
thrush.
Neck
Lymphadenopathy
–
remember
Virchow’s!
Chest
insp.
Spider
naevi,
gynecomastia,
Caput
medusae
Abdo
insp.
Scars,
distension
Palpation
Check
for
pain
1st
6
areas
-‐
Superficial
&
deep.
Liver,
spleen
(hameolytic
anaemias,
infection),
kidneys
balloting
(UTI),
bladder.
Auscultation
Bowel
sounds,
aortic
and
renal
artery
bruits.
Percussion
Inc.
ascites
Groin
Hernia,
lymph
nodes
Leg
Oedema,
gangrene
Extra
PR
exam,
Inguinal
orifice,
ext.
Genitalia,
urinalysis
Review
jaundice,
anaemia,
cyanosis,
clubbing,
lymphadenopathy.
Upper
Peripheral
Neuro
Appearance
Pronator
drift
Tremor,
wasting,
fasciculation
Tone
Shake
hands
while
supporting
elbow:
Power
Pt
birdwings
→
push
down
Support
elbow:
“stop
me
pulling/pushing
your
hand”
Pt
fist
and
Support
forearm:
“stop
me
pushing
up/down/
sides”
Ask
pt
to
turn
palms
up,
thumbs
up
→
try
to
push
thumbs
down
Paper
snatch
Co-‐ordination
Finger
(moving)
to
nose,
piano,
dysdiadochokinesis
Reflexes
Biceps
(indirect),
triceps
(direct),
Supinator
(indirect)
Sensation
Cotton
wool
and
neurotip
(to
sternum
first
for
reference)
Vibration
fork
→
thumb
carpal/metacarpal
Proprioception:
hold
digit
at
sides
and
move
up/down
Cranial
Nerves
1,
Olfactory
“Have
you
noticed
any
change
in
your
sense
of
smell?”
2,
Optic
Acuity
(colour
vision
-‐
Ishihara)
Fields
Reflexes
(light
direct/consensual
and
accommodation)
Ophthalmoscope
(red
reflex,
colour,
contour,
cupping)
3,
4,
6
Oculomotor,
Eye
movements
(nystagmus),
ptosis,
pupillary
size
&
shape
trochlear,
abducent
Ask
for
double
vision
5
Trigeminal
Motor
–
“clench
teeth”
&
feel
masseter/temporalis
Sensory
–
sharp/soft
on
both
sides
in
all
3
CN5
areas
Mention
reflexes:
corneal
and
jaw
jerk
7,
Facial
“Screw
your
eyes
up,
show
me
your
teeth,
blow
out
your
cheeks”
Mention:
taste
ant
2/3
tongue,
hyperacusis
8,
Vestibulocochlear
Hearing
–
Whisper
test,
auroscopy,
Weber,
Rhinnes
9,
10,
Gag
reflex,
“say
ahhh”
→
uvular
deviation
Glossopharyngeal/vagus
Ask
about
swallowing,
hoarse
voice
11,
Accessory
Shrug
shoulders
&
turn
head
against
resistance
(palpate
opposite
SCM)
12,
Hypoglossal
Stick
tongue
out,
wiggle
it
around
Groin
Exposure
Move
trousers
below
curvature
of
bottom
Inspection
Scars,
hernia
Cough
&
watch
Palpate
1) ASIS,/pubic-‐tubercle-‐midpoint,
1
finger
on
deep
ring,
1
on
inguinal
ligament
(superficial
ring)
–
patient
to
cough
2) Same
position
but
with
pressure
on
deep
ring
–
patient
to
cough
again
3) Feel
for
superficial
inguinal
lymph
nodes
4) Femoral
pulse
5) Femoral
canal
–
patient
to
cough
again
6) Listen
to
femoral
artery
(aneurysm)
Stand
patient
up
&
Varicocele,
contralateral
hernia
re-‐examine
for
hernia/ext
genitalia
Breast
Inspection
Asymmetry,
skin
change
Raise
arms
&
watch
Asymmetry
of
movement
Palpate
(lying
flat)
Examine
normal
first
Use
flats
of
fingers,
4
quadrants
+
nipple,
then
axillary
tail
(with
hand
behind
head)
Palpate
axilla
Lift
patient’s
arm
&
move
back
down
after
in
axilla
Supra/infraclavicular
fossa
palpation
Hands
on
hips
to
test
mass
movement
if
located
Thyroid
Inspection
(from
front)
BMI
estimate,
scars,
lumps,
tremor/restless/agitated,
eyes,
hair
&
eyebrows,
stand
from
chair
without
hands
Palpate
thyroid
(Find
thyroid
notch,
move
down
to
just
below
cricoid,
then
lateral)
Ask
to
stick
out
tongue
(thyroglossal
cyst)
Ask
to
swallow
(thyroid)
Uniformly
enlarged,
solitary
or
multinodular?
Percuss
upper
sternum
Mediastinal
extension
Ausc
for
thyroid
bruit
Graves
disease
Lymph
nodes
Ant
cervical,
supraclavicular,
post
cervical,
(explain
process)
submandibular,
submental,
pre-‐auricular,
post-‐auricular,
occipital
[Hard
=
malignant,
tender
=
infection,
rubbery
=
lymphoma]
Eyes
(in
Graves’)
Exophthalmos,
lid
retraction,
lid
lag,
opthalmoplegia,
chemosis
(conjunctival
oedema)
Palpate
parotid
Plus
look
in
mouth
&
examine
facial
nerve
if
lump,
plus
ask
pt
to
open
jaw
to
assess
if
attached
Hands
Temperature,
palmar
erythema,
thyroid
acropachy,
tremor,
pulse
(AF,
tachy),
vitiligo
Palpate
other
lumps
(e.g.
Describe:
site,
size,
shape,
consistency,
fluctuance,
shins–pre
tibial
transilluminance,
temperature,
tenderness,
tethering,
myodema)
pulsatility,
spread
(LNs)
Check
reflexes
Hypothyroidism
GALS
Screen
Qs
Pain,
stairs,
dressing
/
buttons,
gout/arthritis
Gait
Smoothness,
speed,
stride,
symmetry,
swing,
turn
Spine
(back)
Assess
shoulders,
paraspinals,
glutes.
Scoliosis,
Baker’s
cysts,
ankle
deviation
Palpate
supraspinatus
→
fibromyalgia?
Spine
(side)
Lordosis,
kyphosis
Fingers
on
spinous
processes
→
bend
over
slowly
Spine
(front)
Assess
musculature
Ear
→
shoulder:
normal
lateral
cervical
flexion?
Arms
Out
Straighten,
then
elbows
bent
at
side.
(pronated)
Wrist
/
finger
deformity
(Heberden’s=distal
interphalangeal,
Bouchard’s=proximal)
Thenar
wastage
Pitted
nails
→
psoriasis
Metacarpal
squeeze:
pain?
=
Synovitis
Arms
Painful
/abnormal
supination?
(supinated)
Fist
strength?
Pincer
co-‐ordination
and
strength
Wrists
Elbows
out
and
fingers
pointed
up
(extension),
then
down
(flexion)
Shoulder
Hands
behind
head
(elbows
out),
then
up
behind
back
Legs
Asymmetry
of
muscles.
Scars,
swelling,
Knee
effusion
–
patellar
tap.
Active
then
passive
(feel
for
crepitus)
flexion
and
extension
Hips
Check
rotation
on
knee
flexion
Feet
Metatarsal
squeeze,
callous
check.
Shoulder
Inspection
Front,
side,
back
(including
neck)
Muscle
wasting,
scars,
swelling
Palpate
joints
for
muscle
Sternoclavicular
bulk
&
tenderness
Acromioclavicular
Glenohumeral
Palpate
back
of
neck
in
midline
Flexion
of
joint
Stand
behind
patient
&
ask
to
raise
arms
Active
&
passive
(if
active
not
complete)
Abduction
Stand
behind
pt
&
guide
raising
of
arms
Abduct
arms
at
about
30o
(active
&
passive)
External
rotation
Stand
behind
&
position
joints:
Elbows
tight
to
sides
(elbow
joint
at
90o
facing
forward)
Guide
patients
arms
to
externally
rotate
as
far
as
poss
Internal
rotation
Either:
Shoulder
&
elbow
at
90o,
hands
pointing
towards
ceiling
Ask
to
move
wrists
forward
(internal
rotation)
as
far
as
possible
Or:
If
unable
to
lift
arm
to
position
above,
ask
to
put
thumb
behind
their
back
and
see
how
high
they
can
get
it
Compare
each
side
Special
tests:
Arms
abducted
to
90o,
wrist
internally
rotated
Supraspinatus
Patient
to
resist
pushing
down
Subscapularis
Hand
over
umbilicus
Patient
to
try
to
slap
their
tummy
against
resistance
Infraspinatus
Elbows
at
sides
at
90o
(hands
pointing
forwards)
Patient
to
resist
dr
pushing
in
Teres
minor
Shoulder
&
elbow
at
90o
(hands
pointing
to
ceiling)
Dr
pushes
wrists
forward
&
patient
to
resist
Dislocation
tests
Apprehension
test:
Shoulder
&
elbow
at
90o
(hand
pointing
up)
Dr
pushes
humeral
head
from
behind
&
pt
becomes
very
apprehensive
&
tense
(positive
test)
Relocation
test:
Patient
on
bed
in
same
position
as
above
Joint
pushed
posteriorly
&
patient
is
more
comfortable
Hands
Ask
about
pain
and
use
Ask
about
manual
dexterity
–
buttons?
pillow,
don’t
shake
hand
Nails
Observe
and
feel
Psoriatic
pitting,
Swelling
of
MCP/PIP
(RA
→
Fingers
synovitis,
feels
soft),
swan
neck/boutonnieres
deformities
(?),
thumb
z
deformity
(?),
Passive
flexion
→
Trigger
Finger
(Stenosing
tendovaginitis
–
nodes
on
tendon).
IP
Osteophytes:
Proximal=
Bouchard’s,
Distal=Heberden’s
(both
OA)
Ulnar
deviation,
Tophus
(gout)
Pincer
grip
Coordination
and
power
MCP
Squeeze
and
feel
for
crepitus
on
flexion,
lost
inter
MCP
gap
(RA
swelling)
Pt
makes
fist
and
hide
nails
Follow
finger
tendons
Nodules
Palm
Erythema
(RA),
thenar
wastage
(carpal
TS),
Wrist
RA
swelling
and
all
movement
axes
Prayer
and
inverse
Normally
90°
both
ways
prayer
movements
Elbow
RA
nodules
and
gout
tophi
Hip
Gait
Tredelenburg
(pelvic
side
drops
on
raised
foot),
Antalgic
(OA
→
shortened
stance
phase)
Smoothness,
speed,
stride,
swing,
symmetry,
turn
Ask
to
lie
flat
Also
reposition
bed
to
suitable
height
Inspect
from
end
of
bed
Deformities,
scars,
muscle
wasting/fasciculations,
pigmentation,
creases,
swelling,
limb
rotation
Circulation
check
Dorsalis
pedis
Posterior
tibial
Popliteal
(if
none
of
above
found)
Palpate
groin,
greater
Painful
greater
trochanter
(trochanteric
bursitis)
trochanter,
iliac
crest
Abduction
&
adduction
Fixate
opposite
ASIS
&
move
legs
passively
ab
&
adduction
Rotation
(45°
each
Flex
knee
&
hip
&
move
foot
around
direction)
Thomas’
test
Get
patient
to
hold
knees
into
chest
&
feel
obliteration
of
lumbar
lordosis
curvature
→
extend
each
leg
→
Fixed
flexion
deformity?
Turn
Pt
over
Extension
to
20°
Measurement
of
leg
True
length
=
ASIS
to
medial
malleolus
(Perthe’s
disease,
length
avascular
necrosis,
OA,
RA,
hip
dislocation
all
→shortening)
Apparent
length
=
xiphisternum
to
medial
malleolus
(fixed
hip
adduction
deformity
via
OA/RA)
Knee
Get
patient
to
stand
&
walk
up
Gait
abnormality,
leg
alignment
(valgus
=
knock
&
down
knee,
varus
=
bow
leg),
recurvatum/hyperextension
Ask
pt
to
sit
on
couch
(45o
ok)
Feel
knee
Temp.
Inspect
quads
10cm
above
Wastage,
fasciculation
patella
(insertion)
Effusion
Patellar
tap
(and
RA
nodes,
psoriatic
Milk
medial
gutter
inferiorly
plaques)
Milk
lateral
gutter
superiorly
Watch
for
accumulation
of
fluid
medial
to
patella
Request
Active
flexion
To
see
range
of
painless
movement
Passive
Flex
to
90o
&
feel
for
Feel
for
crepitus
during
flexion
joint
line
tenderness
Request
Patellar
Flex
knee
and
press
patella
laterally:
dislocation
→
apprehension
test
instability
→
pain
Extend
knee
fully
Check
range
of
extension
Medial
&
lateral
collaterals
Hold
ankle
underarm,
hand
on
either
side
of
knee.
Perform
initially
on
straight
leg,
then
30°
Medial
Meniscus
Flex
knee,
externally
rotate
foot
and
abduct
thigh
→
varus
stress
Lateral
Meniscus
Flex
knee,
internally
rotate
foot
and
adduct
thigh
Flexion
range
130-‐140o
normal
Look
at
profile
of
flexed
knee
Sagging
of
tibia
(Posterior
cruciate
injury)
Anterior
draw
test
Anterior
cruciate
rupture
Lackman’s
test
(more
20°
flexed
knee,
one
hand
supporting
lower
thigh,
sensitive)
other
proximal
leg.
Draw
leg
anterior
(Anterior
cruciate
rupture)
Clark’s
test
Patellofemoral
ligament,
gentle
pressure
Peripheral
pulses
Posterior
tibial,
dorsalis
pedis
Extras
Also
state
you
would
perform
hip
and
ankle
exams.
FBC,
ESR/CRP,
Xrays