Palpation

Submental Submandibular Anterior Triangle Posterior triangle Pre auricular Posterior auricular Occipital Supraclavicular

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Thank and discuss findings Washes Hands

Inspection

Skin colour
Skin changes
Hair loss and pattern
Amputations
Ulcers

Palpation

Examine both limbs for temperature Palpate for pulses:

Femoral
Popliteal
Posterior tibial
Dorsalis pedis

Capillary refill time Check for peripheral oedema

Special Tests

Buerger’s Test

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Inspection

Deformity
Pulsations
Scars
Dilated vessels

Palpation

Thrills and heaves
Locate apex beat

Auscultation

Mitral area (diaphragm and bell) Tricuspid area (diaphragm and bell) Aortic area (diaphragm and bell) Pulmonary area (diaphragm and bell) Sit patient up and hold breath in expiration while auscultating over left lower sternal edge for aortic regurgitation With patient lying on left side auscultate the apex for mitral stenosis Auscultate carotids

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Inspection

Inspect for:

Scars
Abdominal distension/symmetry
Skin lesions
Visible veins

Palpation

General palpation

Superficial and then deep
Gaurding
Rebound tenderness

Palpation should be systematic and start away from any area of tenderness

Liver Spleen Kidneys

Percussion

Liver Spleen Bladder Ascites(shifting dullness)

Auscultation

Bowel sounds
liver or renal bruit

Examine groin for hernias, lymphadenopathy and external genitalia

Close

Thank and discuss findings Washes hand

Look

Patient standing

Quadricep
Hamstring
Gluteal muscle mass
Trendelenburg test (abductor power)

Gait

Pace
Symmetry
Gross gait abnormalities
Walking aids

Patient lying on couch

Local inspection of the hip for erythema or skin changes
Swelling over greater trochanter
Bruising
Scars
Hair changes
Attitude of the limb
Thomas’ test (fixed flexion deformity)
Limb lengths (true and apparent)

Feel

Greater trochanter Groin (mid-point and medially)

Move

Flexion (active and passive) Internal/External rotation (passive) Adduction/abduction (passive)

Close

Thank the patient Offer to help patient off couch and dress if required Thank and discuss findings Washes hands

Look

Patient standing

Limb alignment
Quadricep/hamstring muscle mass
Popliteal fossae

Gait

Pace
Symmetry
Gross gait abnormalities
Walking aids

Patient lying on couch

Local inspection of the knee for erythema or skin changes
Swelling (generalised or joint effusion)
Bruising
Scars
Hair changes

Feel

Temperature Effusion (medial gutter sweep tests or patella tap) Patella apprehension test Patella grind test Patello-femoral crepitation (knee active flexed/extended) Straight leg raise (confirm extensor mechanism in tact) Tibial tuberosity Patella tendon Medial and lateral joint line +/- Steinman’s test for localised joint line tenderness Medial and lateral collateral ligaments + valgus/varus stressing Lachman’s test (ACL) and Posterior drawer test (PCL)

Move

Flexion (active and passive) Extension (active and passive via heel height testing)

Close

Thank the patient Offer to help patient off couch and dress if required Thank and discuss findings Washes hands

Look

Anterior

Contour of the shoulder
Deltoid and trapezium muscle bulk
Sterno-clavicular and acromio-clavicular joints joint for deformity
Clavicle for deformity
Scars

Laterally

Shoulder contour
Sterno-clavicular and acromio-clavicular joints

Posteriorly

Supraspinatus and infraspinatus fossae for muscle wasting
Scapula for evidence of asymmetry

Axilla

Swellings or scars

Feel

Sterno-clavicular joint Acromio-clavicular joint Acromion Long head of biceps Scapula (spine and body)

Move

(Active followed by passive if limited) External rotation Forward flexion Abduction Internal rotation Scapula winging Rotator cuff power

Supraspinatus
Infraspinatus
Subscapularis

Special Tests

Impingement / Rotator cuff pathology

Painful arc on abduction
Hawkins-Kennedy test (for impingement)
Jobes test
Scarf test

Instability

Sulcus sign
Anterior and posterior drawer tests
Anterior apprehension and relocation test
Posterior apprehension test

Close

Thank the patient Offer to help patient of the couch and dress if required Thank and discuss findings Washes hands

Inspection

Inspect for

Amputations
Ulcers
Hair distrabution
Skin changes
callous

Footwear

Suitability
Wear patterns

Palpation

Temperature Pulses

dorsalis paedis
posterior tibial

Neurological

Inspect

Muscle wasting
Temperature and sweating (autonomic)

Vibration – 128Hz to distal bony prominences Pressure – 10g monofilament

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Thank discuss findings Washes hand

Introduction

Hand Washing Explanation Consent to prodeed General Examination:

Affect
Clothing
Hair
Skin
Pulse
Tremor
Sweatiness
Eye disease: exophthalmos and lid lag
Slow relaxing reflexes

Inspection

Inspect neck from the front and the sides

symmetry or asymmetry
movement of the thyroid on swallowing water
deep breathing to check for stridor

Palpation

Thyroid gland

Size
Symmetry
Tenderness
Movement on swollowing
Texture
Presence of nodules

Cervical lymph nodes

Submental
Submandibular
Pre-auricular
Post-auricular
Occipital
Deep cervical
Supraclavicular

Auscultation

Auscultate for bruits

Close

Thank and discuss findings Washes hands

Look

From behind

Posture of the head, neck and shoulders
Thoraco-lumbar scoliosis (standing, bending forward)

From the side

Cervical lordosis
Thoracic kyphosis (+/- gibus)
Lumbar lordosis

Feel

Supraclavicular fossae (cervical ribs or enlarged lymph nodes) Spinous processes (cervical to lumbar vertebrae). Para-spinal muscles (muscle bulk and note any spasm) Iliac crest heights (asymmetry or excessive pelvic tilt) Sacroiliac joints Chest expansion

Move

Cervical spine

Flexion/extension
Rotation (left/right)
Lateral flexion (left/right)

Lumbar spine

Flexion/Extension (Schober’s test)
Lateral flexion (left/right)

Close

Thank the patient Offer to help patient dress if required Thank and discuss findings Washes hands

Look

Deformity
Generalised swelling
Localised/discrete swellings
Skin changes
Erythema
Scars

Feel

Distal radius including radial styloid Distal radio-ulnar joint (DRUJ) Distal ulna including ulna styloid Anatomical snuffbox +scaphoid compression test Proximal and distal carpal rows Abductor pollicis longus and extensor pollicis brevis tendons for De Quervain’s +/- Finkelstein’s or Eichoff’s test

Move

Flexion
Extension
Radial and ulnar deviation
Pronation
Supination

Special tests

Median nerve exam

Thenar muscle bulk
Sensation (tip of index finger)
Power (abductor pollicis brevis)
+/- carpal tunnel provocation testing (Tinels, Durkins, Phalens)

Close

Thank the patient Offer to help patient dress if required Thank and discuss findings Washes hands

Introduction

Introduction and identification check Explanation Consent to proceed Wash hands check for any pre-existing discomfort Adequately expose patient for examination (bare above elbow)

Universal screen:

Look

Dorsal aspect (Make a fist and open again)

Deformity
Postural abnormalities
Muscle wasting
Focal swellings
Skin changes
Erythema
Scars

Volar aspect (Make a fist and open again)

Deformity
Postural abnormalities
Muscle wasting
Focal swellings
Skin changes
Erythema
Scars
? Triggering (palpate)

Rheumatoid disease:

Look

Wrist / elbow

Swelling (synovitis)
Rheumatoid nodules
MCPJs: Ulnar deviation
PIPJs: Bouchards nodes
Digits: Swan neck / Boutonniere deformities / Z-shaped thumb

Function

Fine pinch (picking up a coin)
Chuck or tripod grip (holding a pen)
Power grip (squeezing your fingers)
Hook grip (resisting decoupling of your hooked hands when pulling away)

Dupuytren’s disease:

Look

Single discrete band vs multiple band
Tethering of the skin
Which digits and which joints are affected
Garrod’s pads

Quantifying

Houston table top test

Measure deformity at each joint using finger goniometer (measure the MCPJ deformity with the PIPJ extended)

Targeted history

When the onset of deformity was
Other areas of the body affected: Feet (Ledderhose), Penis (Pyronie’s)
Risk factors: smoking, alcohol excess, diabetes and manual occupations

Neurological complaint:

Radial

Sensation: Dorsum of 1st webspace
Motor function: Extensor digitorum communis (extension of all four fingers at the MCPJs); Extensor digitorum indicis (extension of index finger at the MCPJ)

Ulnar:

Inspect: Guttering, ulnar clawing
Sensation: Dorsum and volar aspect of little finger
Motor function: ADductor digiti minimi, 1st dorsal interossei, ADductor pollicis (Froment’s test)

Median

Inspect: Thenar and hypothenar muscle bulk
Sensation: Tip of index finger, base of thenar eminence
Motor function: ABductor policis brevis

Hand injury:

Arterial supply
(distal to the injury): Colour of the digits, capillary refill time Neurological supply
(distal to the injury): Injury at the wrist: As described in “neurological complaint”
Injury to a digit: Ulnar and radial digital nerve sensation Extensor injury

Inspect for mallet finger
Test extension at MCPJ, PIPJ and DIPJ

Flexor injury: Test extension at MCPJ, PIPJ (flexor digitorum superficialis) and DIPJ (flexor digitorum profundus)

Close

Thank the patient Offer to help patient dress if required Thank and discuss findings Washes hands

Look

Orthoses or insoles Walking aids. Focal swelling or bruising (in the context of trauma) Medial arch (pes planus, pes cavus). Forefoot (width, hallux valgus, lesser toe deformities) In rheumatoid patients: atrophic skin, curling of the lesser toes, hallux valgus Heel Heel varus Heel valgus Single leg tiptoe test Gait Plantar surface: Callosities, ulcers

Feel

Ankle

Lateral malleolus
Lateral ligament complex
Anterior joint line
Deltoid ligament
Medial malleolus
Tendoachilles

Foot: 5th metatarsal base, 1st and lesser metatarsal heads Arterial supply: Dorsalis pedis, posterior tibial Neuro assessment

Sensation: deep peroneal, superficial peroneal

Move

Ankle

Dorsiflexion
Plantarflexion
Subtalar

Forefoot: 1st MTPJ +/- grind test

Special Tests

Stability: Anterior drawer test Morton’s neuroma: Mulder’s click test Tendoachilles: Simmond’s test

Close

Thank the patient Offer to help patient off the couch and dress if required Thank and discuss findings Washes hands

Look

Deformity Generalised swelling Localised/discrete swellings Skin changes, erythema Scars Carrying angle

Feel

Olecranon Medial and lateral epicondyles Radial head + rotation

Move

Flexion
Extension
Pronation
Supination

Special Tests

Lateral epicondylitis Medial epicondylitis Ulnar nerve exam

Interossei muscle bulk
Sensation (dorsal and volar aspect of little finger)
power (adductor digiti minimi; first interossei; Froment’s test)
+/- cubital tunnel provocation test (Tinels)

Close

Thank the patient Offer to help patient off the couch and dress if required Thank and discuss findings Washes hands

Inspection

Inspect external genitalia

Hair distribution
Vulval skin
Pubis
Labia majora and minora
Clitoris
Perineum
Urethra meatus
Perianal region

Gently part labia to inspect introitus Asking the woman to cough may demonstrate stress incontinence/prolapse

Bimanual Palpation

Lubricate gloved index and middle finger of gloved dominant hand Part the labia with index and middle finger of the left hand Insert two fingers of dominant hand gently avoiding the sensitive clitoris and urethra Lay non dominant hand over the suprapubic region Palpate the cervix Note cervical excitation- (extreme pain on palpation of the cervix) Move dominate hand fingers into posterior fornix Assess position of uterus- if anteverted will be palpated between posterior cervix and non-dominant hand If retroverted the cervix will be anterior and the uterine body lies posterior to this- so not palpable between hands Palpate the uterus between hands for mobility, regularity and size Bilaterally palpate for adnexal masses by moving dominant hand to vaginal fornix and non-dominant hand to coinciding iliac fossa Palpate the Pouch of Douglas via the posterior fornix for any pelvic mass

Speculum

Lubricate speculum (if smear use minimal gel on blades or use water so as not to contaminate smear test) Part the labia using dominant finger and thumb Insert speculum blades at 3oclock rotating to 12oclock as inserted Insert speculum fully in a 45 degree angle towards the coccyx Open speculum blades to visualise cervix Inspect for vaginal discharge, vaginal wall mucosa, cervix and prolapse Remove speculum- let blades close partially in order to visualise the vaginal walls whilst ensure not catching vaginal wall tissue

Swabs

Take a high vaginal swab and endocervical PCR swab Label specimens and complete microbiology request form

Smear

Visualise cervical os Rest tip of brush in os Rotate clockwise ten times Place brush in medium and check tissue removed from brush into medium by ‘dunking’ the brush against the base of the pot and rotating it anti-clockwise. Secure lid Label jar and complete cytology request

Close

Thank the patient Offer to help patient dress if required Remove gloves and wash hands Thank and discuss findings

Inspection

Distention of abdomen Fetal movements Skin- striae gravidarum, linea nigra, scars, rash or tense and shiny

Palpation

Calculate symphysio-fundal height Fundus is located by palpating the uterus using the ulnar border of the left hand Hold the tape measure at the fundus and measure blinded (i.e. measuring side down) down to the upper border of the symphysis pubis in the midline (20 weeks= 20cm, at umbilicus, grows 1cm per week should equate to gestation +-2cm until 36 weeks Feel the uterus using gentle pressure from both hands and noting any irregularities, tender areas, liquor volume, and determine fetal poles Lie- axis of the fetus in relation to mothers spine-longitudinal/ transverse/oblique Presentation- part of baby at pelvic brim- cephalic/ breech/ back/ limbs Engagement- how far the fetal head has moved into the pelvic inlet. Engagement is assessed using Powliks grip (thumb and index finger of right hand) or by palpating with both hands over the lower pole (Engaged if less than 2/5ths palpable)

Auscultate

Place funnel of stethoscope over anterior shoulder of fetus and ear on flat end of stethoscope

Close

Thank and discuss findings Washes hands

Introduction

Introduction and identification check Explanation Confirm chaperone present Consent to proceed Check for any pre-existing discomfort Wash hands and put on gloves Position patient sitting up on edge of bed Adequately expose patient for examination (waist up)

Inspection

Begin by asking the patient to rest her hands on her thighs, with her arms relaxed Look for asymmetry, scars, obvious lumps, swellings or skin changes (Peau d’orange) Look for nipple abnormalities such as discharge or nipple inversion Repeat inspection with patients hands above head Repeat inspection with patients hands pressing hands into hips (to tense pectoralis muscle)

Palpation

Ask patient to place hand behind head Palpate breast with palm of hand Work outside of breast in to nipple Ensure axillary tail is examined Ensure nipple is examined Ask patient to reproduce nipple discharge if present Ask patient to swap which hand is behind head and examine the other breast in the above manner Examine the axilla by supporting the weight of the patients arm in yours and Using other hand examine the anterior, posterior, medial, lateral and apex of axilla for lumps and lymphadenopathy Repeat this examination for the other side Bilaterally feel for supraclavicular lymphadenopathy

Close

Cover the patient Thank and discuss findings Remove gloves and wash hands

Assess tone

Rigidity – flex and ext at elbow, supinate and pronate wrist Spasticity – flex and ext at elbow, supinate and pronate wrist

Assess Power

Shoulder abduction Elbow flextion and extension Wrist flextion and extension finger abduction Finger flextion and extension Thumb abduction

Assess Reflexes

Biceps triceps supinator

Assess Co-ordination

Look for tremor – intention, resting, postural

Assess Sensation

First hypothesis pattern of sensory loss. Light touch Proprioception Vibration Pain/temperature Thank and discuss findings Washes hand

Assess tone

Rigidity – int and ext rotation of hip, flex and ext of knee, test for ankle clonus Spasticity – int and ext rotation of hip, flex and ext of knee, test for ankle clonus

Assess Power

Hip flexion and extension knee flexion and extension ankle dorsiflex and plantarflex big toe flexion and extension,

Assess Reflexes

Patellar Ankle Plantar

Assess Co-ordination

Heal shin test, gait

Assess Sensation

First hypothesis pattern of sensory loss. Light touch Proprioception Vibration Pain/temperature Thank and discuss findings Washes hand

I Olfactory Nerves

Each nostril can be tested separately by using a variety of smells.

II Optic nerves

Visual acuity Record visual acuity using a Snellen chart at 6 metres. Note the effect of refractive errors (measure with and without glasses). Observe the effect of the use of a pinhole in those with refractive errors. Visual fields Assess visual fields Plot blind spots Pupils: Observe the direct and consensual responses to light. Assess for the presence of a “relative afferent pupillary defect’ Observe the response to convergence. Optic fundus (fundoscopy)

III, IV, VI Oculomotor, trochlear and abducens nerves

Examine horizontal and vertical smooth pursuit eye movements Examine convergence. Examine horizontal and vertical saccadic eye movements Observe Bell’s phenomenon (the upward deviation of the eyes on eye closure). Assess whether or not ptosis is present.

V Trigeminal nerve

Test light touch and pain sensation on each division of the trigeminal. Elicit the corneal reflexes (afferents Vth, efferents VIIth). Evaluate contraction of temporalis and masseters. Elicit the jaw jerk (afferents Vth, efferents Vth).

VII Facial nerve

Examine for the presence or absence of facial weakness, including assessment of brow wrinkling, eye closure, smiling to show teeth and mouth closure.

VIII Auditory and Vestibular nerves

Examine the external auditory canal. Assess hearing clinically and perform and interpret Rinne’s and Weber’s tests.

IX, X Glossopharyngeal and vagus nerves

Assess soft palate movement Test sensation on the posterior wall of the pharynx on the left and right Elicit the gag reflex from the left and right (afferent IXth, efferent Xth).

XI Accessory nerve

Test the power of trapezius and the sterno-mastoid muscles.

XII Hypoglossal nerve

Assess the tongue for wasting and fasciculation, and test tongue movements and power. Thank and discuss findings Washes hand

Inspection

On observation comments on Truncal ataxia

Gait & balance

Assesses for ataxic or broad based gait Heel toe walking

Tone/reflexes

Assesses for hypotonia and hyporeflexia

Coordination

Finger nose test - intention tremor or past pointing and/or Heel-shin test Dysdiadochokinesia Nystagmus

Speech

Assesses for cerebellar speech; slurred/staccato speech Thank and discuss findings Washes hand

End of bed & general examination

Inspection of surrounding area, general condition, body habitus Hands – koilonychia, pallor of palmar creases Skin – petechiae, purpura, jaundice, skin infections Eyes – conjunctival pallor, jaundice Mouth – angular stomatitis, smooth or beefy tongue, oral candidiasis, inspect tonsils and tonsillar bed

Neck Examination

Inspect

Masses, asymmetry Swallow (ask patient to take a mouthful of water, hold it and then swallow whilst observing neck)

Palpate

Submental Submandibular Anterior triangle Posterior triangle Pre-auricular Post-auricular Occipital Supraclavicular Axillary lymph node examination: Apply gloves, palpate the medial, anterior and posterior walls of the axilla and towards the axillary apex.

Abdominal Examination

Lie the patient flat Inspect for any scars or swellings (including the inguinal regions) Inguinal lymph node examination: Palpate for horizontal and vertical inguinal lymph nodes Palpate the liver Palpate the spleen (if you do not feel the spleen repeat with the patient on their right side) Percuss the liver Percuss the spleen

Close

Thank and discuss findings Washes hands

Hands

Inspect both hands:

For example:
Clubbing
Koilonychia
Splinter haemorrhages
Cigarette stains

Dorsal aspect Palmer aspect Capillary refil time

Radial Pulse (Rate. Rhythm. Character. Volume. R=L?) Blood Pressure

Head

Skin Eyes Mouth and Tounge

Neck

Inspect Palapate lynph nodes

Submental
Submandibular
Pre-auricular
Post-auricular
Anteriar traingle
Posteriar triangle
Occipital
Supraclavucular

Carotid pulse Carotid Bruit

Close

Thank and discuss findings Washes Hands