Gastrointestinal System Presenting Complaints •
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Appetite changes – anorexia, hyperphagia
Patient lying supine with one pillow
Weight loss (malabsorption, malignancy, diabetes, thyroid, IBD, eating disorder, depression )
Inspection General – age, gender, comfort/distress
Weight gain Dysphagia (oesophagus, nodes, goitre) goitre) Nausea / vomiting – onset, frequency, contents (infection, (infection, inflammation, obstruction) obstruction ) Haematemesis – frank or coffee ground (ulcer, (ulcer, varices, Mallory Weiss tear, malignancy )
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Abdominal pain – colicky (biliary, (biliary, GI ), ), severe ( peritonitis ( peritonitis)) Jaundice (haemolysis, liver, biliary ) Change in bowel motions – volume, frequency, consistency, colour, tenesmus, blood
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PMH – abdominal surgery Family – colorectal cancer, haemochromatosis, IBD, ulcers Medications – NSAIDs (ulcers), metformin (diarrhoea), opioids (constipation), antibiotics (bowel changes), bisphosponates (oesophagitis), SSRIs (nausea) Social – smoking, alcohol, IV drugs, travel, vaccinations, birth country
Red Flags •
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Indigestion / heartburn – reflux
Patient History •
Examination
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Mental state – alert, confused, coma Body habitus – weight, wasting, oedema, hydration Colour – pallor, jaundice, haemochromatosis
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Hepatic flap Arms/shoulders – spider naevi (oestrogen), oestrogen ), bruising, wasting, scratch marks (?obs (?obs jaundice) jaundice ) Eyes – xanthelasma, icterus, conjunctival pallor, uveitis, KayserFleisher rings (Wilson’s (Wilson’s disease) disease ) Salivary glands – parotid & submandibular glands & ducts Lips – hydration, agular cheilitis, ulceration, pigmentation, telangiectasia Mouth – foetor, stomatitis, candidiasis/leukoplakia (L won’t scrape off, C will), gums, glossitis, central cyanosis, teeth
Chest – spider naevi (oestrogen (oestrogen), ), loss of hair distribution, gynaecomastia (oestrogen (oestrogen)) Abdomen – scars, striae, bruising, stoma, distension (8 Fs), masses, veins, peristalsis, pulsations
Palpation Superficial – tenderness, masses •
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Vital signs – Temp, HR, BP, RR, O 2 Hands – leukonychia (↓albumin), albumin), koilonychia (spooning, ↓iron), iron), clubbing (cirrhosis, (cirrhosis, IBD), IBD), pallor in palmar creases, palmar erythema (oestrogen), oestrogen ), wasting, dupuytren’s contracture
Lymph nodes – cervical & axillary
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Deep – masses, guarding, rigidity, rebound tenderness, McBurney’s point,Rosving’s sign Liver & gallbladder (Murphy’s sign) Spleen Kidneys Abdominal aorta
Percussion Liver Bladder Shifting dullness • • •
Auscultation Bowel sounds Epigastric bruits Renal bruits • • •
Other •
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DRE – inspection (fissure, fistula, tags, blood, rash, ulcer, mucus); palpation (wall consistency; prostate size, surface, tenderness) Urinalysis Pregnancy test Bowel chart
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Sudden onset of pain Increasing severity of pain Syncope / pre-syncope Vomiting Haematemesis Abdominal distension Pallor & sweating Tachycardia & atrial fib rillation Hypotension Fever Rebound tenderness, guarding, rigidity Oliguria / anuria Positive pregnancy test
Respiratory System Presenting Complaints •
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Cough – nature, onset, wet (viral, ( viral, LRTI, COPD, bronchiectasis), bronchiectasis), dry (viral, asthma, GI reflux, restrictive, ACEi ), ), night (asthma (asthma LVF, post-nasal drip), drip), morning (smoking (smoking), ), whooping, bovine (laryngeal (laryngeal nerve), nerve), croup Sputum – colour, volume, type (purulent, mucoid), blood Haemoptysis – acute (malignancy (malignancy ), ), chronic (bronchiectasis (bronchiectasis), ), pink frothy ( pulmonary oedema ) Dyspnoea / shortness of breath – onset, nocturnal (asthma/LVF (asthma/LVF ), ), on waking (COPD (COPD), ), duration, relieving factors, severity, exertional change
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Patient sitting upright, general inspection then entire back exam → entire front exam Inspection General – age, gender, body habitus, oxygen equipment, posture (?dyspnoeic), respiratory distress, cough, sputum •
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Wheeze (high pitch) – when, ∆ with coughing, exercise (asthma ( asthma)) Stridor (inspiratory rasp) – onset (respiratory obstruction ) Chest pain – nature, intensity, exertional change (chest ( chest wall, pleura or mediastinal causes )
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Sleep apnoea – snoring or waking up dyspnoeic (airway (airway obstruction) obstruction ) Voice change - dysphonia, aphonia
Patient History •
Examination
PMH – hay fever, eczema, HIV Family – atopy, CF, α1-antitrypsin, TB asbestos, same symptoms
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Occupation – asbestos, chemicals
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Meds – ACEi, β-blockers, NSAIDs
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Social – smoking, travel, pets
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Hands – clubbing ( pus ( pus in lungs), lungs ), peripheral cyanosis, wasting (brachial plexus), plexus), pallor in creases Asterixis (CO2 retention) retention ) Radial pulse, respiratory rate, breathing (Cheyne-Stokes = alternating, Kussmaul = shallow)
Palpation Back – Back – chest expansion, tenderness, spring chest (front, back, sides), tactile fremitus Front – tenderness, tactile fremitus, apex beat (lying)
Nose (straight in) – polyps, enlarged turbinates, displaced septum Mouth – central cyanosis, erythema, tonsils, exudates, candidiasis Voice Sinuses – frontal, ethmoidal, maxillary Lymph nodes – cervical & axillary
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Trachea – cartilage, tug, deviation Chest – shape, symmetry, scars, tattoos, scoliosis, pigeon chest, funnel chest, barrel chest, breathing
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Percussion Lungs (remember dullness over liver & heart) •
Auscultation Breath sounds - vesicular (normal (normal ), ), bronchial (hollow, consolidation) consolidation ) •
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Eyes – conjunctival pallor, Horner syndrome (miosis, partial ptosis, lower lid elevation, enopthalmos, anhydrosis)
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Red Flags
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Added sounds – stridor (inspiratory, upper airway obstruction) obstruction ) wheezing (narrowed (narrowed airways), airways ), crackles (fine=fibrosis (fine=fibrosis,, medium= pulmonary medium= pulmonary oedema , coarse= pneumonia/COPD coarse= pneumonia/COPD ), pleural rub ( pneumonia, pneumonia, infarction ) Vocal resonance
Other • • •
Temperature Pulse oximetry Spirometry – FVC, FEV 1, PEFR
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Haemoptysis – URTI, LRTI, bronchiectasis, bronchial carcinoma Sudden onset dyspnoea – ? PE or pneumothorax Sudden onset stridor – anaphylaxis, inhaled foreign body, acute epiglotitis (may block airway), gas inhalation
Cardiovascular System Presenting Complaints •
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Chest pain – crushing (MI (MI ), ), angina (tight, retrosternal, exertional), sharp inspiratory ( pericarditis, pericarditis, pleuritic ), ), interscapular (dissecting (dissecting aneurysm, back pain), pain ), acid taste/burping (GI (GI reflux ), ), chest wall (costochondritis, rib fracture, skin ) Dyspnoea – precipitating factors, exertional (CCF, (CCF, angina), angina), orthopnoea (CCF, (CCF, LVF ), ), paroxysmal nocturnal dyspnoea (LVF, (LVF, silent MI ) Palpitations – fast (SVT (SVT , heart cond., hyperthyroid, stress, meds ), slow Peripheral oedema – where, when, pitting (CCF (CCF ), ), generalised (kidney, liver ), ), unilateral (DVT, (DVT, lymph obstr.) obstr.)
Examination Patient sitting initially and lying at 45° (starting at neck)
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Sputum – pink frothy (LVF (LVF ) •
Patient History •
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PMH – HTN, lipids, BMI, diabetes, CKD, AF, previous cardiac events, rheumatic fever, renal disease, Marfan / Downs / Turner syndrome Family – IHD, lipids, HTN, CKD, DM, sudden cardiac death Meds – T4 (angina), angina), β-agonists (↑HR), HR), β-blockers (↓HR) HR) Social – smoking, IV drugs (IE (IE ), ), alcohol ( AF, ( AF, HTN ), ), job (pilot / driver)
Chest Lying 45° Inspection – scars, deformities, pacemaker / defibrillator, visible apex beat •
Inspection Sitting General – age, gender, comfort, dysmorphism (Downs, Turner, Marfan), mental state, body habitus, oedema
Syncope / prepre -syncope –postural ( postural hypotension ), lightheaded, sudden collapse (arrhythmia (arrhythmia)) Leg pain – calf (DVT ( DVT ), ), exertional (intermittent claudication) claudication )
Red Flags
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Surroundings - cigarettes, O 2 devices, GTN spray, holter monitor, ECG leads Colour – pallor (anaemia/ (anaemia/ vasoconstriction), vasoconstriction ), cyanosis Hydration status Hands – pallor of nail bed, peripheral cyanosis, capillary refill, clubbing (congenital (congenital heart disease, IE ), ), xanthomata, signs of infective endocarditis (Janeway lesions, splinter haemorrhages, Osler nodes) Arms - radial pulse (rate, rhythm), radio-radial delay (aortic ( aortic coarctation, subclavian stenosis), stenosis ), respiratory rate, blood pressure (+pulsus paradoxus) Eyes – xanthelasma, conj. pallor Mouth – central cyanosis, higharched palate (Marfan ( Marfan), ), gums, dentition (poor → ?IE ) Neck ( Neck (lying 45°) – JVP, carotid pulse (rhythm, character)
Palpation - apex beat, thrill (LVF ( LVF ), ), heave (palpable murmur) Diaphragm of steth (A,P,M,T,axilla) – heart rate, heart sounds (S 1, S2, S3, S4), carotid, murmurs (intensity, timing, location, breathing insp→↑right, exp→↑left)
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Bell of steth – mitral area
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Left lateral position (MS) MS)
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Sitting forward holding breath after expiration ( AS, ( AS, AR, pericardial rub) rub)
Abdomen Palpate – tenderness, masses, organomegaly, AAA •
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Auscultate – aortic, renal, iliac, femoral bruits
Back Sitting • • • •
Inspect – scars, deformities Palpate – sacral oedema Percuss – lung bases (effusion ( effusion)) Auscultate – lung bases
Lower Limbs Inspection – varicose veins, colour, trophic ∆s (thin/dry/shiny skin, hair, nails, ulcers), xanthomata, clubbing Palpation – temp., tenderness, pulses (F, P, PT, DP), pitting oedema •
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Irregularly irregular pulse (arrhythmia e.g. AF ) Six Ps (acute limb ischaemia) ischaemia ) – pallor, pulseless, pain, paraesthesia, perishing cold Unilateral leg swelling (DVT ) Very sudden & severe tearing pain (thoracic aortic dissection) dissection )
Musculoskeletal System Presenting Complaints •
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Pain – site, symmetry, radiation, mono/polyarticular, acute/chronic, bone, nociceptive/neuropathic, inflammatory/noninflammatory Morning joint stiffness – brief & worse w/ movement (osteoarthritis (osteoarthritis)) vs. prolonged & improved with exercise (rheumatoid (rheumatoid arthritis) arthritis ) Muscle stiffness ( polymyalgia rheumatica ) Joint abnormalities - locking (loose body, meniscal tear ), ), instability (ligamentous stretching / rupture), rupture), triggering (tendon thickening) thickening) Swelling – location, shape, size, consistency, surface texture, mobility, tenderness, pulsation
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Loss of function Other symptoms – fever, weight loss, bowel symptoms, urethritis, uveitis, conjunctivitis, dry mouth Simple backache – mechanical pain in 20-55 y.o. Nerve root pain – unilateral leg pain, motor / sensory change
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Family – RA, OA, gout, osteoporosis
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Meds – analgesics, NSAIDs
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Loss of function – brushing teeth (elbow (elbow ), ), buttoning shirt (wrist, (wrist, hands, hands, walking (lower (lower limb) limb )
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General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Rashes, scars, erythema, swelling, gluteal folds, popliteal folds, bursae (supra-, infra-, pre-patellar)
Special Tests Patella apprehension ( patella dislocation ) – apply laterally directed force on medial patella with thumbs (feels like patella will dislocate) •
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Muscles (wasting, spasm) – esp. quadriceps Deformities – genu valgum (knock-knee), genu varum (bow-leg), genu recurvatum (back-knee) Gait & posture – leg length, 10 steps, sitting, squat
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Skin temperature
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Quadriceps - tenderness, wasting, spasm
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Bursae – supra-/infra-/pre-patellar, popliteal
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Significant trauma History of cancer or osteoporosis IV drug user Immunosuppressed
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Feel
Cauda equina syndrome – urinary/ faecal incontinence, perineal anaesthesia, leg weakness
PMH – joint or back problems, IBD, anterior uveitis, urethritis, malignancy
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Patient History •
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Knee Examination
Tenderness (inflamm., infection) infection) Skin changes – erythema, shiny skin, ulceration, rash ( psoriasis, ( psoriasis, SLE )
Regular night sweats Unintentional weight loss Constant (day & night) pain >50 or <20 years old
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Ligaments & tendons – M & L collateral ligaments, biceps, semimembranosus, semitendinosus tendons
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Patella tap – slide hand down thigh to upper edge of patella, tap on patella (clunk → effusion) effusion ) Bulge test – stroke hand medial, up & around to lateral patella (bulge in medial patella → effusion) effusion )
Move Supine, stabilise pelvis with other hand Active → passive (crepitus) → resisted •
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Bony landmarks – joint line, femoral condyles & epicondyles, fibular head, Gertie’s tubercle, patella
Flexion (closing), extension (opening), internal rotation, external rotation
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Collateral ligament stress test – supine (once 20° once straight); brace medial knee & apply varus force (medial collateral ligament), brace lateral knee & apply valgus force (lateral collateral ligament) Anterior & posterior draw test (start by looking for posterior draw) – sit on patient’s foot, both hands around upper tibia, thumbs over tibial tuberosity, pull forwards (anterior cruciate lig), push backwards (posterior cruciate lig) (laxity/pain) Lachman’s Test (anterior cruciate ligament) – supine, 15° of flexion, examiner’s knee under their knee, stabilise femur & apply pressure to posterior upper tibia (laxity/pain) McMurray’s test – valgus force on lateral knee, flex to 90°, hold sole of foot, rotate leg internally & extend knee (lateral meniscus); varus force on medial knee, flex to 90°, hold sole of foot, rotate leg externally & extend knee (lateral meniscus) (pain) Apply’s grind test – prone, prone, knee flexed to 90°; compress knee while internally & externally rotating (medial & lateral menisci), pull on knee while internally & externally rotating (collateral ligaments)
Hip Examination
Ankle & Foot Examination
Spinal Examination
Look
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General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Deformities (true/false scoliosis), swelling, scars, gluteal folds, popliteal creases, ASIS level Muscles (gluteus, adductors, iliopsoas, quads) – wasting, spasm Gait & posture – walking 10 paces, sitting, squatting
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Swellings (hernia) Landmarks – greater trochanter of femur, ASIS, PSIS, ischial tuberosity, pubic symphysis Leg length – true (ASIS → medial malleolus) vs. apparent (umbilicus → medial malleolus)
Flexion (anterior), extension (posterior, prone (posterior, prone), ), adduction (medial), abduction (lateral), internal rotation, external rotation
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Thomas test (fixed flexion hip deformity ) – patient supine, bring knee a to chest (leg b raises off ground → deformity in leg b) Trendelenberg test (glut med weakness, short femoral neck, unstable hip) hip ) – hold patient’s hands, ask them to stand on foot a and lift foot b off ground (hip b falls)
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Footwear – abnormal, asymmetric, poor fit, orthotic Ankles – swelling, bruising, deformities, tibialis posterior, FDL, FHL Feet – posture, arch, skin changes, colour, swelling, rashes, ulcers, infection ,calluses, plantar surface Toes – alignment (straight, hammer, claw, mallet), nail changes, swelling, hallux valgus (bunions ( bunions))
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Muscles – gluteus, adductors, iliopsoas, quadriceps
Move Supine, stabilise pelvis with other hand Active → passive → resisted •
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Feel Supine •
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Skin – scars, rashes, ulcers
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Muscles – bulk, wasting, spasm
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Foot – navicular bone, calcaneus (medial tubercle), MTP & IP joints, metatarsal heads, tendons (TA, FHL, FDL), DP pulse
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Tibiotalar joint – dorsiflexion, plantar flexion
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Subtalar joint – inversion, eversion
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Chopard’s joint – toe dorsiflexion & plantar flexion
Special Tests Thompson’s test (calcaneal tendon) – prone – prone,, foot over edge of bed, squeeze calf muscles (no passive plantar flexion)
Foot posture
Muscles (wasting / spasm) – levator scapulae, trapezius, semispinalis capitus, rhomboids Bones & ligaments – costochondral & sternochondral joints
Prone
Move Active → passive → resisted •
Joints – swelling, deformities (scoliosis, thoracic kyphosis, loss of lumbar lordosis)
Feel Supine
Temperature Ankle – distal 1/3 of fibula, malleoli, tendons (peroneal, tibialis posterior), joint line, PT pulse
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast), gait, cushingoid facies
Muscles (wasting / spasm) – SCM, scalenes, levator scapulae, erector spinae, gluteal, hamstrings Bones & ligaments – spinous processes, interspinous ligaments, cervical facet joints, costovertebral articulation, sacroiliac joint
Move •
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Cervical – flexion (down), extension (up), L / R lateral flexion (tilt), L / R rotation (turn), extension + rotation Thoracic & lumbar – extension (back), flexion (forward), L / R rotation (sitting, turn), L / R lateral flexion (hand down thigh)
Special Tests Femoral nerve stretch (L3 radiculopathy ) – prone, prone , flex knee with hand on hamstring (pain in femoral nerve distribution) •
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Straight leg raise (sciatic nerve) nerve) – supine, supine, flex hip with leg straight (pain in back of leg from 30-70°)
Shoulder Examination
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General – age, gender, body habitus, comfort Skin changes, symmetry, posture, swelling, deformities (scoliosis, dislocation)
Scapular winging (push against wall)
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Temperature Bony landmarks – SC joint, clavicle, AC joint, acromian, subacromial space, coracoid, scapula, thoracic vertebrae Muscles – as above
Move Bilaterally at the same time for comparison Active → passive → restricted •
Flexion (forward), extension (backward), abduction (laterally, externally rotate at 90°), drop-arm test (internally rotate while coming down) adduction (medial), internal rotation, rotation , external rotation (flexed 90°), push shoulders back
Special Tests Apply’s scratch test – patient reaches over opposite shoulder (adduction), behind neck (adduction & external rotation), behind back (internal rotation) •
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Neer’s test (subacromial impingement ) –flex patient’s straight arm with their thumb down (pain)
Elbow Examination Look
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Muscles (wasting / spasm) – deltoids, biceps, triceps, supraspinatus, infraspinatus, trapezius, rhomboids, pectoralis major, latissimus dorsi
Apprehension/relocation test (anterior stability) – supine, supine , abduct patient’s arm to 90° & externally rotate & apply posterior pressure to humerus (apprehension of dislocation), internally rotate & apply anterior pressure (relocation)
Supraspinatus tests – resisted internal rotation into abdomen (Napoleon test); resisted internal rotation away from back (lift off test); resisted abduction from 90° + resisted abduction from 30° while internally rotated (empty can test) (pain) HawkinsHawkins -Kennedy test (impingement ) – flex patient’s elbow & shoulder to 90°, support shoulder & forcibly internally rotate shoulder (pain)
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General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast)
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Swelling, asymmetry, deformities, nodules
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Rashes – anterior (eczema (eczema), ), posterior ( psoriasis) psoriasis )
Feel •
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Bony landmarks – olecranon, lateral & medial epicondyles, head of radius, radiohumeral joint Muscles – flexors & pronators (medial), extensors & supinators (lateral), brachioradialis Tendons (triceps, b iceps), ulnar nerve
Move Active → passive → resisted Flexion, extension, pronation (palm down), supination (palm up), flexion in semipronation (brachioradialis) •
Special Tests Lateral epicondylitis tests – resisted wrist extension with extended elbow; resisted middle finger extension; tight fist (pain) •
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Medial epicondylitis – resisted wrist flexion (pain) Valgus & varus stress tests – elbow flexed to 20° and supinated, support humerus and gently stress medial side (lateral ligaments) and then lateral side (medial ligaments) of the elbow joint Nerve entrapment tests – extend thumb (radial), abduct thumb (median), adduct thumb (ulnar)
Wrist Examination Look •
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General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Scars, rashes, colour, wounds, nail changes, wasting, swelling, ganglia, deformities, symmetry Nerve lesions – wrist drop (radial (radial ), ), hand of benediction (median (median), ), claw hand (ulnar (ulnar )
Feel •
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Dorsal wrist – distal forearm, ulna, radius, lunate, metacarpals, snuff box, PIP & DIP joints Palmar wrist - pisiform, hook of hamate, flexor retinaculum, Guyon’s canal Hand – swelling, tenderness, warmth, nodules
Move Active passive resisted (not resisted for wrist) Wrist – flexion, extension, ulnar deviation, radial deviation, pronation, supination •
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Fingers – flexion, extension, abduction, adduction Thumb – opposition, abduction, adduction, flexion, extension
Special Tests Phalen’s test (median nerve compression) compression ) – reverse prayer sign (flex wrists), normal prayer sign (pain) •
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Tinel’s sign (carpel tunnel syndrome) tunnel syndrome) – percuss over flexor retinaculum (paraesthesia) Nerve entrapment tests – extend thumb (radial), abduct thumb (median), adduct thumb (ulnar)
Neurological System Presenting Complaints •
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Headache – onset, severity, location, aggravating factors, relieving factors
Cranial Nerve Examination
Upper Limb Neuro Examination
Upper Limb Neuro Examination
Patient sitting on edge of bed
Patient sitting on edge of bed
Patient supine
Inspection Posture (decerebrate), nerve signs (wrist drop, claw hand, hand of benediction), muscles (wasting, fasciculations), tremor at rest, abnormal movements, skin change
Inspection Gait - 10 steps
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Vision changes – blurring, diplopia, flashes Hearing/balance changes – vertigo, tinnitus, hearing loss Weakness in face, arms, legs – time course, generalised / specific, unilateral / bilateral, proximal / distal, sudden (vascular (vascular ) Burning, tingling, numbness
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Fits, faints, mood changes – aura, LOC, tongue biting
Patient History •
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PMH – neurological events, HTN, DM, AF, CV risk factors, pregnancy Family – neurofibromatosis, tuberose sclerosis, Hungington’s disease, Friedrich’s ataxia, DMD Medications Social – toxin exposure, alcohol, smoking, level of function
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Grading Guide •
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Tone – flaccid, decreased, normal, increased Power - 0 (no contraction), 1 (flicker), 2 (w/o gravity), 3 (vs. gravity), 4 (mild resistance), 5 (normal) Reflexes – 0 (absent), + (reduced), ++ (normal), +++ (~increased), ++++ (greatly increased
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Inspection – craniotomy scars, neurofibromas, facial asymmetry, ptosis (Horner’s, (Horner’s, oculomotor lesion, myasthenia gravis), gravis ), exophthalmos, enothalmos, eye deviation, pupils Olfactory (CN I) – ask patient re: smell, inspect nares, present smells Optic (CN II) – visual acuity, visual fields (peripheral & central), fundoscopy (disc, retina) Eye reflexes (CN II, III) – inspection (shape, size, ptosis), direct response (ipsilateral), consensual response (contralateral), swinging light test (partial), accommodation Eye movement (CN III, IV, VI) – modified H, asking about diplopia Trigeminal (V) – sensation (light touch, pain), corneal reflex (opthalmic facial), muscles of mastication & jaw jerk (mandibular)
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Facial (VII) – raise eyebrows, close eyes, smile, puff out cheeks Vestibulocochlear (CN VIII) – otoscopt, auditory acuity (rub fingers), Weber’s test (forehead), Rinne’s test (mastoid ear)
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Accessory (XI) – torticollis (tilted head), turn head vs. resistance (SCM), shrug vs. resistance (traps)
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Tone – active movement, passive movement (elbow & wrist), grade (flaccid, , normal, ) Power – movement vs. resistance Reflexes – biceps (C5, C6), triceps (C7, C8), supinator (C5, C6) Coordination – finger-nose test (their nose examiner’s finger), rapid alternative movement (quickly turning hand over)
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Pain – dermatomes Vibration (128Hz) – pulp of middle finger, ulnar styloid process, olecranon, clavicle etc.
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Proprioception – distal IP joint
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Soft touch - dermatomes
Walking on heels (L4/L5), toes (L1) Tandem walking – R heel in front of L toe etc. (cerebellar ( cerebellar lesion) lesion) Proximal myopathy – sit & rise without assistance, Trendelenberg test (stand on one foot, supported) Proprioception – stand, feet together, eyes open (station), closed (Romberg test) General inspection – skin, muscles (wasting, fasciculations)
Motor
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Sensory
Throat (IX, X) – say ahh, gag reflex, hoarseness, cough Hypoglossal (XII) – protrude tongue, deviate each side, push vs. cheek
Positional drift – (arms out, eyes closed) - down & pronation (weakness), weakness ), up & pronation (cerebellar disease), disease ), all directions (loss of proprioception )
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Tone – active movement, passive movement Clonus – push on superior patella, rotate then dorsiflex ankle (UMN ( UMN ) Power – movement vs. resistance Reflexes – knee (L3, L4), ankle (S1, S2), Babinski (L5, S1, S2) Coordination – drag heel down shin & back up; toe-finger test (bed examiner’s finger), rapid alternating movement (tap foot against palm of hand quickly)
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Pain – dermatomes Vibration (128Hz) – 1st metacarpal head, malleoli, patellae, ASIS
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Proprioception – distal IP joint
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Soft touch - dermatomes
Urinary System
Diabetes
Presenting Complaints
Complications of Diabetes
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Dysuria – infection or inflammation
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Frequency – infection, inflammation, outlet obstruction, decreased capacity
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Polyuria – excess water intake, diabetes mellitus, diabetes insipidus, kidney disease
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Nocturia
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Urgency
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Hesitancy / dribbling
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Incontinence – urge / stress incontinence
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Weak stream – obstruction
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Change in urine colour – haematuria (infection, (infection, trauma, stones, cancer ), ), medications, foods (beetroot)
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Pain – abdominal, loin
Urinary Examination Patient sitting on edge of bed •
General – confusion, drowsiness, hyperventilation (metabolic (metabolic acidosis), acidosis ), hydration
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Hands – leukonychia, pallor of palmar creases, asterixis (severe ( severe kidney failure) failure )
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Arms – AV fistula, bruising, pigmentation, scratch marks, sensation ( peripheral peripheral neuropathy ), neuropathy ), pulse, blood pressure (other arm if AV fistula is present)
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Face – pallor, jaundice, uraemic foetor (kidney ( kidney failure), failure), mouth ulcers, candidiasis, gingivitis
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Neck – Neck – JVP (fluid (fluid overload ), ), carotid bruits
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Metabolic - acute Diabetic ketoacidosis – dehydration, Kussmaul breathing Nonketotic hyperosmolar coma - dehydration Hypoglycaemia – agitation, weakness, SNS activation Macrovascular Coronary artery disease – angina, MI Stroke Peripheral vascular disease – claudication, gangrene Infection Microvascular Retinopathy – macular oedema, retinal damage & angiogenesis Neuropathy – abnormal / sensation Nephropathy – chronic renal failure • • •
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Diabetic Examination •
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Legs o
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Chest (auscultate) – signs of CCF, pulmonary oedema, pericardial rub, consolidation Abdomen o Inspect – peritoneal dialysis catheter, scars (nephrectomy, ( nephrectomy, transplant ), ), distension (ascites (ascites)) o Palpate – masses, liver, kidney, bladder, AAA o Percuss – shifting dullness, bladder o Auscultate – renal bruit (renal (renal artery stenosis) stenosis ) o DRE – prostatomegaly
Inspection – age, sex, body habitus, hydration, signs of Cushings / acromegaly / haemochromatosis, consciousness (ketoacidosis), ketoacidosis ), Kussmaul breathing (short & shallow, ketoacidosis) ketoacidosis )
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Inspect – skin colour, skin quality (dry, cracked, hairless), ulcers, infections (tinea, gangrene), muscles Palpation - temperature (cold/blue vascular disease, hot/red DVT), capillary refill, peripheral pulses Sensation – light touch, pain, vibration, proprioception Motor – knee & ankle reflexes, squat & stand (proximal myopathy) tone, power, coordination
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Arms – nail candidiasis, blood pressure (lying & standing)
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Eyes – visual acuity, reflexes, eye movements
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Mouth – signs of infection
Back – Back – palpate vertebral column (bony ( bony tenderness), tenderness), renal angle (renal ( renal tenderness), tenderness), sacral oedema
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Ears – signs of infection
Legs Inspect – oedema, purpura, pigmentation, scratch marks, gouty tophi Palpate – pitting oedema, peripheral pulses, sensation ( peripheral ( peripheral neuropathy ) neuropathy )
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Neck – Neck – carotids (palpate & auscultate)
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Abdomen – liver
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Fundi – changes due to hypertension / diabetes
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Temperature
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Urinalysis
Investigations Urinalysis – glucose, ketones, protein Fasting glucose – short term control HbA1C - ~3-month control • • •
Thyroid
Haematological System
Presentations
Presenting Complaints
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Hyperthyroidism - appetite, weight loss, diarrhoea, sweating, dry skin, hair thinning, preference for cold Hypothyroidism - appetite, weight gain, constipation, lethargy, heavy periods, preference for warm weather
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Thyroid Disease Examination Examination
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Hyperthyroidism
Hypothyroidism
General
Weight loss, anxiety
Mental / physical slowness, voice change
Hands
Tremor, onycholysi s (nail separates from b ed), clubbing, palmar erythema, sweaty palms
Peripheral cyanosis, pigmentation, cool / dry hands, pallor
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Pulse
Sinus tachycardia / atrial fibrillation
bradycardia
Face
Exophthalmos (sclera visible below iris & eye protruding beyond orbit Grave’s disease), disease ), lid retraction (sclera visible above iris), lid lag
Skin pigmentation (hypercarotinaemia (hypercarotinaemia ), skin thickening, alopecia (hair loss), periorbital oedema, xanthelasma, swelling of tongue
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Patient History • • •
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Inspection - scars (thyroidectomy (thyroidectomy ), ), veins (retrosternal (retrosternal goitre), goitre ), redness (suppuratives (suppuratives thyroiditis), thyroiditis ), swelling (generalised / localised), during swallowing (moves superiorly normal, goitre, thyroglossal cyst) Palpation (from behind ; lobes & isthmus) – size; shape; nodules; thrill (hyperthyroidism (hyperthyroidism); ); fixation (carcinoma (carcinoma); ); consistency: consistency : firm (goitre (goitre), ), rubbery hard (Hashimoto’s (Hashimoto’s thyroiditis), thyroiditis ), stony hard (thyroiditis (thyroiditis), ), tenderness (thyroiditis (thyroiditis))
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Percussion – upper part of manubrium (retrosternal (retrosternal goitre) goitre )
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Auscultation – over each lobe for bruits (hyperthyroidism, (hyperthyroidism, antithyroid medication )
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Peberton’s sign (thoracic inlet obstruction e.g. retrosternal goitre ) – patient lifts both hands as high as possible, look for signs of congestion / cyanosis / respiratory distress Chest (auscultate heart & lungs) – systolic flow murmur, CCF, pericardial / pleural effusion (all hyperthyroidism) hyperthyroidism )
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Legs – pretibial myxoedema (bilateral, firm, elevated dermal nodules; Grave’s disease), disease ), non-pitting oedema (hypothyroidism), hypothyroidism ), reflexes ( hyperthyroidism, hyperthyroidism , hypothyroidism )
PMH – infections, fever, chills Social – diet (meat) Menstrual history – blood loss
Examination
Thyroid Examination Patient sitting on edge of bed
Tiredness Weakness Dyspnoea Fatigue Postural dizziness Bruising Blood in stool Lumps – neck, armpit, groin
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General - age, gender, racial origin (thalassaemia (thalassaemia), ), pallor (anaemia (anaemia), ), bruising (coagulopathy (coagulopathy ), ), jaundice (haemolytic anaemia), anaemia), scratch marks (lymphoma (lymphoma)) Hands – koilonychias, pallor of nail beds / palmar creases, bruising Radial pulse (tachycardia) tachycardia ) Lymph nodes (site, size, fixation, consistency, tenderness) – cervical, axillary, trochlear, supraclavular Face – scleral icterus ( jaundice ( jaundice), ), conjunctival pallor, gums, oral mucosa, tongue (glossitis), tonsils Chest – press sternum & clavicles with heel of hand, push shoulders together Abdomen – masses, liver, spleen, inguinal nodes Legs – bruising, pigmentation, scratch marks, ulcers, sensation, popliteal nodes Other – fundoscopy (papiloedema, haemorrhage), temperature, urinalysis, rectal / pelvic examination
