General
Mental state; personal care; features; clinical syndromes; posture
Pulse, blood pressure, respiratory rate, temperature
Hands: skin (palm and dorsum) color, temperature, moisture, palmer erythema, cyanosis, staining (nicotine, bruising, rashes), pigmentation, tone, thickness, laxity, senile changes Oslers nodes, rheumatoid changes, Dupuytren’s contracture
Nails: bitten, pallor, spooned, clubbing, splinter hemorrhages
Muscles: wasting, abnormal movements, flap
Lymphadenopathy
Head and Neck
Cranial Nerves:
I: smell
II: visual acuity, color vision, visual fields, fundoscopy
III,IV,VI: pupillary responses to light and accommodation, extraocular movements, ptosis, lid lag, nystagmus, enophthalmus, exophthalmos
V: sensation over the three divisions; corneal reflex, muscles of mastication, jaw jerk
VII: facial expression, whistle, blowing out cheeks against resistance, taste anterior two-thirds tongue
VIII: hearing: watch, whisper, Rinne’s and Weber’s tests IX: gag reflex, taste posterior third tongue
X: voice, cough, uvular deviation, swallow
XI: shoulder shrugging, neck rotation, head nodding XII: tongue movements
Nose: deformity, airway, bleeding
Eye: Conjunctiva: inflammation, chemosis, pallor, subconjunctival hemorrhage
Sclera: red, yellow, blue, brown
Mouth:
Lips: telangiectasia, swelling, ulceration, pigmentation, Koplik’s spots, cleft
Gums: gingivitis, hypertrophy, retraction
Teeth: discolouration, caries, periodontal disease
Tongue: glossitis, atrophy, macroglossia, geographic tongue, ulceration, leukoplakia, neoplasia
Tonsil: redness, purulent discharge, gag reflex
Oropharynx: redness, coated, purulent discharge, fetor
Salivary glands: tenderness, swelling, abscess, cysts, tumors, duct calculi
Face:
Congenital features, Cushing’s, acromegaly
Facial palsy: upper/lower motor neurone
Cachexia, weight loss, edema
Neck:
Trachea: deviation, tug
Thyroid: palpable, enlarged, symmetrical, focal lump, cyst, benign, malignant tumours, tracheal deviation, retrosternal extension, bruit, movement on swallowing
Carotid arteries: enlargement, bruits, jugular venous pressure, hepatojugular reflex
Lymph nodes: submental, submandibular, preauricular, postauricular, occipital, deep and superficial cervical lymph chains
Neck movements
Musculoskeletal System
History: localise symptomatic muscles, joints, bones
Pain, stiffness, limited movement, creaking, cracking, locking, giving way, swelling, wasting, contractures, deformities, loss of function
Manual dexterity: dressing, toiletry, eating, writing
Mobility: ability to sit and stand, walking distance, independence, need for assistance or mechanical aids, work and recreational activity
Symptoms of inflammatory disorders: fever, malaise, ocular problems, urethritis, diarrhea
Examination: pain at rest/on movement, Cushingoid, Paget’s deformity, weight, fever, malaise, inflammatory eye conditions, blue sclera, gouty tophi, digital trophic changes
Nails: color, discolouration, pitting, ridging, hyperkeratosis
Compare bones, joints and muscles of the two sides of the body. Ensure appropriate exposure and record any abnormalities of asymptomatic joints
Look: skin: creases, scars, color, erythema, atrophy, rashes, sinuses
Shape: swelling of bone, bursae, synovium, effusions, bony alignment (valgus/varus), subluxation, dislocation, shortening, deformity, wasting
Position: at rest and during activity
Hand deformities: swan neck, boutonnier’s, z thumb, finger drop, mallet finger, Dupuytren’s contracture, Heberden/Bouchard nodes, ulnar deviation
Posture: kyphoscoliosis, neurological and myopathic abnormalities, Trendelenburg test
Feel: skin, soft tissue and bones, warmth, tenderness, thickening, nodules, overgrowth, deformity
Abnormal bursae/synovial thickening
Effusions: reducible, fluctuant, ballottable, transillumination
Fractures: tenderness, deformity
Move: active, passive and resisted movements in each joint plane
Pain, power, tone, range, creaking, crepitus, clicking, triggering, locking, hypermobility, telescoping, contractures, stability
Fracture: abnormal mobility, crepitus.
Deformity: mobile or fixed
Hand: ability to grip, pinch and do up shirt buttons
Gait: spastic, ataxic, waddling, limp, use of mechanical aids
Measure: range of joint movements (goniometer)
Limb circumference at equivalent levels from fixed bony points on the limbs on each side
True and apparent leg shortening, Bryant’s triangle
Proceed to X-ray and image symptomatic areas, to identify abnormal bone and soft tissues
Female Breast
History: Pain: cyclical/persistent
Lump: generalized/discrete, duration, change, previous history
Discharge: milk, pus, blood, serous (color)
Menstrual history: pregnancy, breast feeding, pill and hormone replacement
Family history
Examination: secluded, warm area with subject undressed to waist
Sitting, reaching up, leaning forward, lying
For each breast: pillow behind shoulder and hand behind head
Look for: symmetry, mobility, flattening, swelling, skin dimpling, redness, peau d’orange, ulceration, submammary edema, lumps
Palpate: each quadrant, the retroareolar area and the nipple, for nodularity (general/focal), lumps, mobility
Express from the nipple
Axillary nodes: anterior, medial, posterior, lateral, apical, infraclavicular, supraclavicular
Liver enlargement, spinal tenderness
Cardiovascular System
History: Pain: angina, central chest (radiation), back
Palpitations, edema, cyanosis, fatigue, syncope
Cough, sputum, hemoptysis; dyspnea, orthopnea, paroxysmal nocturnal dyspnea
Hypertension, diabetes, hypercholesterolemia, smoking, family history of vascular disease
Symptoms of stroke: visual, speech, motor, sensory, cranial and peripheral nerves, memory
Claudication, pain in feet at rest, foot ulceration, gangrene
Examination: Marfan’s, Down’s, Turner’s syndromes, cachexia
Hands, fingers and nails: clubbing, peripheral cyanosis, nicotine staining, splinter hemorrhages, Osler’s nodes
Head and neck: jugular venous pressure (cannon waves, CV systolic waves), hepatojugular reflex, xanthelasma, pallor, jaundice, central cyanosis, malar flush, fundi
Arterial pulse: rate, rhythm, volume, character, thickening of vessel wall
Tachycardia, bradycardia, sinus arrhythmia, premature beats, atrial fibrillation, hyperdynamic, collapsing (Corrigan), bisferiens alternans, pulsus pardoxus
Radio-femoral delay, radial asymmetry, cardio-peripheral deficit
Peripheral pulses: presence, symmetry, volume, bruits
Blood pressure: standing/lying
Respiratory rate, temperature
Heart: lying at 45 degrees, repeated in supine, rotated and sitting positions, on to Valsalva and squatting manoeuvres
Position, force and character of apex beat, abnormal pulsaton, thrills, cardiac outline, scars
Auscultation with bell and diaphragm over mitral, aortic, pulmonary and tricuspid areas, repeat during inspiration and expiration, and appropriate positions
Sounds: first and second, splitting, third and fourth, summation gallop, opening snap, ejection click, mid/late systolic click, pericardial knock/rub
Timing of onset and offset of murmurs in relation to systoli, diastoli and valve closure, point of maximum intensity, grade, radiation, effect of positional and respiratory manoeuvers
Systolic: aortic stenosis, HOCM, mitral regurgitation, mitral valve prolapse, ventricular septal defect
Diastolic: aortic regurgitation, mitral stenosis
Continuous: patent ductus arteriosus, venous hum, pulmonary arteriovenous malformation, ruptured coronary sinus
Lungs for basal crepitations, pulmonary effusion
Hepatomegaly, liver pulsation, ascites, peripheral edema
Feet: pulses, trophic changes, pressure sores, ulceration, gangrene, inflammation, abscess formation, neuropathy, postural changes, venous filling time
Respiratory System
History: upper respiratory tract infection, nasal discharge, nasal obstruction, pain over sinus or in ears, cervical lymphadenopathy
Chest pain: related to respiration, angina
Cough: day/night time, dry, productive, sputum (appearance and volume), hemoptysis
Breathlessness: at rest, on exercise, orthopnea, paroxysmal nocturnal dyspnea, wheezing
Pyrexia, rigors, cyanosis, edema, myalgia
Examination: cough, sputum (examine sputum pot: colour, consistency, volume)
Pulse, blood pressure, respiratory rate, temperature
Hands, fingers and nails: clubbing; peripheral cyanosis, nicotine staining, wasting of small muscles, wrist tenderness, carbon dioxide retention flap
Head and neck: conjunctival pallor, jugular venous pressure, Horner’s syndrome, hoarseness of voice
Cervical and axillary nodes
Chest: pattern of respiration, rate, depth, tachypnea, dyspnea, irregularity, stridor, use of accessory muscles, Cheyne-Stokes
Anterior chest wall configuration: pectus excavatum, pectus carinatum
Scars, prominent veins
Vertebral column abnormalities: buffalo hump, barrel chest, lordosis, kyphoscoliosis
Palpate tracheal deviation, tracheal tug
Chest expansion: manual assessment and tape measure
Tactile vocal fremitus, subcutaneous emphysema, rib tenderness
Percussion: resonant, hyper-resonant, dull, stony dull
Coarse percussion.
Auscultation: use bell and diaphragm
Breath sounds: normal, vesicular, bronchial, bronchovesicular
Adventitious sounds: crackles (râles), wheezes (rhonchi)
Vocal resonance: egophony, whispering pectoriloquy
Pleural friction rub
Alimentary and Genitourinary Systems
History: weight (current, changes), fatigue, pigmentation
Pain: site, radiation, relation to food
Flatulence, nausea, vomiting, hematemesis
Dysphagia: site, solids/fluids
Stool: frequency, quantity, consistency, mucus, blood (fresh, altered, melena), tenesmus
Perianal pain; lump, discharge, pruritus
Micturition: frequency, nocturia, polyuria, oliguria, hematuria, obstruction, hesitancy, poor stream, dribbling, urgency, dysuria
Urethral discharge/pain
Urine: amount, discoloration, clarity, color, blood, debris
Menstruation: menarche, menopause, dysmenorrhea, menorrhagia, amenorrhea
Dyspareunia: superficial/deep, vaginal discharge, contraception
Pregnancy: past obstetric history, last smear, last menstrual period, expected date of delivery, abdominal pain, vaginal bleeding, venous thrombosis
Examination: presence and features of any vomitus
Weight loss, cachexia, dehydration, obesity, hypo/hyper pigmentation, encephalopathy
Hands: palmer erythema, telangiectasia, Dupuytren’s contracture, skin laxity, muscle wasting, arthropathy, liver flap
Nails: pallor, clubbing, spooning, leukonychia, onycholysis
Head and neck: conjunctival pallor, jaundice, xanthelasma, halitosis (hepatic, uremic, faecal, ketotic), tongue (dry, furred, glossitis, leukoplakia), gingivitis, dentition
Salivary glands: tenderness, swelling
Cervical lymphadenopathy (NB: scalene node)
Abdomen: lying supine with a single pillow, fully exposed, but breasts and genitalia covered until these areas are examined
On inspection: skin: laxity, pigmentation, bruising, scratch marks, stria, hair distribution, scars, sinuses, fistulas, stomas, dilated veins, herniae, divarication of the recti
Umbilicus: position, hygiene, nodules, discharge, hernia
Distension: scaphoid abdomen, respiratory movements, visible peristalsis
Enlarged organs: liver, gall bladder, spleen, bladder, uterus, masses
Discomfort on blowing out/drawing in abdominal wall and coughing
On percussion of the four quadrants: rebound tenderness, hyper- resonance, position of organs (liver, spleen, bladder, uterus), masses, ascites, shifting dullness
On palpation: NB: watch patient’s face throughout. In children and with sensitive abdomens, start with self-examination to identify tender areas
Superficial/deep four quadrant, tenderness, guarding, rigidity
Organs: liver, gall bladder, spleen, kidneys, bladder, uterus, colon/faeces
Masses: stomach, pancreas, uterus, ovarian, large/small bowel, retroperitoneal
Aorto-iliac aneurysms
Ballottable organs/masses, fluid thrill, sacral edema
On auscultation: gut sounds: normal, absent, tinkling, increased
Friction rub
Renal, aorto-iliac bruits/hums
Succussion splash
Inguinal/Femoral Hernia
If not obvious ask the patient to stand
Observe site, overlying skin, cough impulse, reduction by patient
Palpate for tenderness, cough impulse, reducibility, anatomical position of neck, controllability
Inguinal/axillary nodes
External Genitalia
Draw scrotum forward onto the front of the thighs
Observe symmetry, skin, scars, rashes
Swellings: inguino-scrotal, scrotal (testis, epididymis)
Palpate: testis, epididymis, spermatic cord
Relation of cyst/masses to testis/epididymis
Penis: circumcised, retractable foreskin, position and shape of meatus, balanitis, discharge
Rectal/Vaginal examination
Nervous System
History: current mental state: level of consciousness, orientation, memory (recent, long term), intellect, understanding, insight, thought content, behaviour, mood, hallucinations, delusions
Prior injury, stroke, transient ischemic attack
Headache, fits, faints, falls, dizziness
Disturbances of vision/speech, diplopia, visual loss, dysarthria, dysphasia, aphasia
Disturbances of motor or sensory function of limbs/face, dysesthesia, clumsiness, weakness
Examination: NB: compare the two sides of the body
Handedness
Speech: dysphasia (expressive, receptive, global), jargon, scanning, stuttering, dysarthria
Motor function: tone: spasticity, flaccidity, rigidity, clonus
Power: hand grips, wrists, elbows, shoulder, ankles, knees, hips
Coordination finger-nose, heel-shin, dysdiadochokinesis, pyramidal drift
Reflexes: tendon, superficial
Abnormal movements: tremor (static, intention), choreiform, athetoid, convulsions, associated movements, tics
Muscle: wasting, hypertrophy, fasciculation
Abnormalities of posture: upper/lower motor neurone, extrapyramidal, cerebellar, sensory, myopathic, Romberg’s sign, standing on toes, walking backwards on heels, heel-toe
Gait: spastic, ataxic, waddling, limp
Sensory function: nerve root, spinal cord level, hemianesthesia
Light touch: cotton wool
Pain: pinprick
Temperature: finger/tuning fork
Vibration: start distally on wrist and ankle
Position sense: hold sides of digit
Graphesthesia: use threes and eights
Two-point discrimination: blunt compass, start on hand
Stereognosis: coins, keys
Spinal deformity/tenderness, neck rigidity
Palpate and percuss abnormal superficial nerves
Map out areas of altered sensation
Contractures, neuropathic joints, ulceration
Carotid bruits
Autonomic: sweating, postural hypotension, heart rate response to a Valsalva manoeuvre