Physical examination
Cardiovascular system
Check bedside cabinet
Position patient at 45 degrees
“Have you any pain anywhere?”
General
Cyanosis, pallor, dyspnoea
Hands and arms
Wasting, cyanosis, clubbing, splinter haemorrhages, pallor,
Osler’s nodes, Janeway lesions
Pulse (bilateral radial, rate, rhythm, character, radio-femoral delay,
collapsing)
Blood pressure
Eyes, ears, mouth and
neck
Xanthelasma, corneal arcus, icterus, pallor
Diagonal ear crease
Central cyanosis, sublingual veins, high arched palate
JVP (inspect, time, occlude, reflux)
| Praecordium | |
| Inspection | scars, visible pulsations, visible apex beat |
| Palpation | palpable thrill, apex beat |
| Auscultation | SI, SII, added sounds |
| Bell at mitral area (lean to left, relocate apex beat, exhale) (MS) | |
| Diaphragm at mitral, tricuspid, pulmonary and aortic areas, carotids for bruit (AS) | |
| Sit up, exhale, tricuspid area (AI) |
Other
Lung bases, sacral oedema
Hepatomegaly if JVP, tricuspid regurgitation
Abdominal aneurysm, bruits & femorals
Peripheral pulses (femoral, popliteal, posterior tibial, dorsalis pedis)
Peripheral oedema
Respiratory system
Check bedside cabinet
Position patient at 45 degrees
“Have you any pain anywhere?”
General
Cyanosis, pallor, dyspnoea, tachypnoea, stridor, wheeze, lip pursing,
chest shape, use of accessory muscles
Hands and arms
Wasting, cyanosis, clubbing, tar staining, pallor, asterixis
Pulse (rate, rhythm, character, collapsing)
Eyes, mouth and neck
Pallor
Central cyanosis
Central trachea, crico-sternal distance
(JVP [inspect, time, occlude, reflux], then apex beat)
| Chest (front AND back) | |
| Inspection | scars, asymmetry, paradoxical breathing |
| Palpation | chest expansion, tactile vocal fremitus |
| Percussion | asymmetry (dullness, hyperresonance) |
| Auscultation | breath sounds, added sounds (rhonchi, wheeze, stridor, crepitations), vocal resonance |
Examine front, then back, then neck for lymphadenopathy
Gastrointestinal system
Check bedside cabinet
Position patient flat on bed
“Have you any pain anywhere?”
General
Icterus, cachexia, pallor
Hands and arms
Wasting, clubbing, leuconychia, koilonychia, pallor,
Dupuytren’s contracture, palmar erythema, asterixis
Pulse (rate, rhythm, character)
Spider naevi
Eyes, mouth, neck and
trunk
Xanthelasma, corneal arcus, Kaiser-Fleischer rings, icterus, pallor
Angular cheilitis, Peutz-Jegher, stomatitis, glossitis, ulcers,
leukoplakia, candidiasis
(JVP [inspect, time, occlude, reflux])
Supraclavicular lymphadenopathy
Gynaecomastia, loss of hair
| Abdomen | |
| Inspection | scars, moves on respiration, masses, visible pulsations, shape, herniae (lift head and cough) |
| Palpation | tenderness (rebound/guarding), masses, organomegaly (liver, spleen, kidneys), pulsations, ascites |
| Percussion | hepatomegaly (?downwards displacement), splenomegaly, ascites (shifting dullness, fluid thrill) |
| Auscultation | bowel sounds, bruits (organs, blood vessels) |
Other
Rectal examination
Peripheral oedema
Genitalia (testicular atrophy, loss of hair)
Neurological system
General
Posture
| Limbs | |
| Inspection | asymmetry (wasting, position, fasciculation, tremor), pronator drift |
| Palpation | Tone increased (clasp-knife,
lead-pipe, cogwheel) or decreased Power (isometric) Reflexes x2, then reinforce Co-ordination Sensation proprioception, light touch, pain, temperature, vibration (actual feeling, "Does it feel normal?" [compare with forehead]), asymmetry |
| Upper limbs | |
| Tone | feel over tendons, move wrist |
| Power | shoulder shrug: trapezius (C3,4) shoulder abduction: deltoid (C5) elbow flexion: biceps (C5,6) elbow extension (radial n.): triceps (C7) wrist extension (radial n.): ext. carpi radialis (C6,7,8) median nerve: power grip (C8, T1), thumb/pinky opp: (C8, T1), thumb abduction: (C8, T1) ulnar nerve: abduct/adduct fingers (C8, T1) |
| Reflexes | biceps (C5,6) triceps (C7) supinator (C5,6) Hoffman’s (hyperflex DIP joint, thumb flexes) |
| Co-ordination | dysdiadochokinesis, dysmetria, dyssynergia, rebound overshoot |
| Sensation | proprioception at MCP joint light touch (cotton wool) pain (pin-prick) temperature (cold object [metal]) vibration (Hz) |
| Lower limbs | |
| Tone | roll leg, watch big toe lift knee quickly move foot, test for clonus |
| Power | hip flexion (femoral n.): ilio-psoas (L1,2,3) hip extension: gluteus maximus (L5, S1,2) knee extension (femoral n.): quadriceps (L2,3,4) knee flexion (sciatic n.): hamstrings (L4,5, S1,2) dorsiflexion (sciatic n.): tibialis anterior (L4,5) plantarflexion (sciatic n.): gastrocnemius/soleus (S1,2) |
| Reflexes | quadriceps (L2,3,4) ankle (S1,2) Babinski crossed adductor (tap vastus medialis, contralateral limb adducts) |
| Co-ordination | heel-shin pendulum reflex |
| Sensation | proprioception at MTP joint light touch (cotton wool) pain (pin-prick) temperature (cold object [metal]) vibration (Hz) |
| Romberg’s test | stand up, feet together, hands outstretched, eyes closed (if worsens there is a proprioceptive defect) |
| Gait |
Cranial nerves
Inspect face
| I | ask about recent change in smell |
| II | AFRO (Acuity,
Fields, Reflexes, Ophthalmoscopy) acuity in each eye visual fields pupillary reflexes (direct, consensual, accomodation) fundoscopy |
| III, IV, V | eye movements, diplopia, nystagmus, lid lag |
| V | clench teeth hold mouth open, hold mouth closed jaw jerk sensation (including corneal reflex) |
| VII | raise eyebrows, screw up eyes puff out cheeks, smile, whistle |
| VIII | hearing (free-field testing) |
| XI, X | uvula and soft palate elevate without deviation, gag reflex (uvula deviates away from affected [weaker] side) |
| XI | hold head still against resistance, shrug shoulders |
| XII | tongue fasciculation, stick it out, move from side to side (tongue deviates towards affected [weaker] side) |
Thyroid gland
General
Signs of hyper- or hypothyroidism
| Neck | |
| Inspection | swelling, moves on swallowing, stick out tongue |
| Palpation | palpable?, define margins/character/etc., swallow, trachea |
| Percussion | retrosternal goitre |
| Auscultation | bruits |
Thyroid status
| General | |
| Hyper | restless, sweaty, weight loss, gynaecomastia, palpitations, heart failure, hepato- or splenomegaly, lymph nodes (esp. axillae), osteoporosis |
| Hypo | lethargic, slow, weight gain, hoarse voice, deafness, dry skin, myxoedema |
| Hands and arms | |
| Hyper | hot,
sweaty, tremor, acropachy, onycholysis (4th finger), palmar erythema pulse (rate, rhythm, character, collapsing) tachycardia, atrial fibrillation systolic hypertension with wide pulse pressure, spider naevi |
| Hypo | cold,
dry, pallor bradycardia |
| Hair, face, eyes and neck | |
| Hyper | fine
thin hair exophthalmos/lid retraction, lid lag, ophthalmoplegia, diplopia goitre, bruit, percuss sternum |
| Hypo | dry
brittle hair, loss of eyebrows and hair "peaches and cream" periorbital oedema, pallor |
| Lower limbs | |
| Hyper | proximal
myopathy pretibial myxoedema (deposition of mucopolysaccharide) hyperreflexia |
| Hypo | proximal
myopathy slow-relaxing ankle reflexes oedema, cold peripheries |
Other
Signs of other autoimmune diseases
Vascular system (lower limbs)
| Inspection | skin colour, dry skin, diminished sweating, loss of hair, venous guttering, ulcers (pressure areas, between toes) |
| Palpation | temperature, capillary/vein filling time, Buerger’s angle, pulses |
| Auscultation | bruits |
Other
Sensation, power
Varicose veins
Ask patient to stand up
| Inspection | site, extent, size, skin - chronic venous hypertension (brown pigmentation, eczema, ulceration) |
| Palpation | skin
texture, pitting oedema/thickening/redness/tenderness
(lipodermatosclerosis), cough impulse in groin tourniquet, Trendelenburg and Perthes tests elevate leg - empty veins, tourniquet, stand |
| Percussion | full veins transmit impulse |
| Auscultation | bruits |
Other
Abdominal examination (obstructing masses)
Testes