CVS EXAM RESP EXAMOverall inspectBody habitus, Pt comfort, Obvious oedema, Down Syndrome, Turner’s, Marfans, skin colouration /pigmentation/drugs and equipment

HandsColour/Cyanosis/Temperature/Capillary refill/Janeway lesions/Oslers nodes/Splinter haemorrhages/Clubbing/Pallor/Tobacco stains/Tendon Xanthomata / long fingers in marfans

Pulse and BP – check both arms, RR delay, BP lying and standing (orthostasis)

NeckJVP <3cm/Carotid pulse vol and character/bruits

FaceEyes – conjunctivae pallor or icterus/corneal arcus/xanthalasma/fundoscopy would be idealCheeks – malar flush (MS and PS)Mouth –high arch palate/cyanosis central/dentition

ChestDeformities/Scars/observe any visible pulsationsDO CAPILLARY REFILL AT STERNUMPalpate – thrills/heaves/apex beatAuscultate – Heart soundsLung Bases – percuss and listen

AbdomenPulsatile liver/masses/AAA/bruits in renal arteries/Femoral pulses and radio-fem delay / Ascites

LegsPVD signs/Oedema/Pulses/Scars/Calf tenderness/Temperature

Overall inspectBody habitus/breathing and comfort/drugs and equipment/sputum sample/ oxygen /cyanosis/ cough

HandsClubbing/Cyanosis/Capillary refill/ Pallor/Muscle wasting/Wrist tenderness/Tobacco stains/Asterixis = CO2 Flap

Pulse and BP and RR and Temperature – pulsus paradoxus (increased HR on inspiration and exaggerated decrease in BP on inspiration)

Face and ask patient to say their name or where they live (assess voice)Plethora-Venous congestion (pembertons sign)/Central cyanosis/Pallor of conjunctivae/Horner’s syndrome (ptosis, miosis, anhydrosis)/ Voice hoarseness (recurrent laryngeal nerve palsy)

CHECK FOR TENDERNESS OF THE SINUSESLOOK IN THROAT FOR REDNESS ETC

TRACHEAMid-line? Deviation/Tug

NeckJVP <3cmMUST DO LYMPH NODES Offer to check thyroid – retrosternal goiter and PEMBERTONS SIGN

ChestBack first – observe scars, chest shape, deformitiesCHEST EXPANSION >5cm normal/ Percuss for dullness/Palpate for vocal fremitis/Palpate for subcutaneous pneumothorax/Listen for breath sounds and vocal resonanceFront last – observe scars and deformities or shape of chest/ Palpate for subcutaneous emphysema and vocal fremitis PLUS Apex beat/Auscultate breath sounds/ Auscultate heart sounds for S2Test for pembertons sign

Abdomen and LLPulsatile liver? Congestion? Ascites/OedemaCalf tenderness for DVT and ?PE

GIT EXAM CRANIAL NERVESOverall InspectionBody habitus-thin or fat?/Comfort/Colouration of skin (haemochromatosis, jaundice, Addisons, Anaemia)/Ascites/Distended abdomen/ Scratch marks/Bruises/Spider naevi/consciousness ? / encephalopathy/Rashes!In men – hair distribution / gynaecomastica /

HandsPalmar erythema/Clubbing /Leukonychia/Pallor/Dupytren’s / Telangiecstases/ contracture/Tobacco stains/Tendon Xanthomata / ASSESS FOR HEPATIC FLAP 15secs(ASTERIXIS)Pulse and BP and Temperature etc ArmsBruising/Petichiae/Scratch marks/Spider naevi/muscle wasting and proximal myopathy seen in etOH abusers/ Palpate the axillary lymph nodes

FaceXanthalasma/Corneal arcus/Kayser Fleisher rings/ Pallor / Telangiecstasia/Peutz-Jeghers/Mouth dentition and fetor hepaticus/ Candidiasis/ Apthous ulcers/Gums/cheilosis and glossitis/ white spots on tongue in zinc deficiency / Parotiditis? Check this too as associated with etOH abuse/ Submandibular gland

NeckJVP <3cmCervical lymph nodes and left supraclavicular nodes (Troisier’s sign = enlarged left supracalv node + stomach ca)

ChestSpider naevi <4/Chest hair pattern/Gynaecomastia (oestrogen or spironolactone or digoxin use)

AbdomenInspect – scars, rashes/ striae/ observable pulsations or visible peristalsis, distention/oedema, colour, bruises, scratch marks/ CHECK FOR A HERNIA BY LIFTING PTS HEAD

CNI OlfactorySmell testCN II OpticFundoscopyLight reflex with consensual responseAccomodationVisual Acuity = snellen’s chart (with glasses)Visual Fields (without glasses)CN III, IV, VILight reflex and accommodationEye movements – ask pt to tell if there is any diplopia(diplopia that persists when one eye is covered can be due to astigmatism, a dislocated lens or hysteria). Look for NystagmusCN VSensory ophthalmic, maxillary, mandibular divisionsMotor Temporalis and masseterJaw jerk reflex exaggerated in pseudobulbar palsyCorneal reflex (V and VII)CN VIIStapedius muscle (chorda tympani nerve)Anterior 2/3 tongue taste – can test this or offer toFacial muscles wrinkle forehead, smile, frown, puff out cheeks, close eyes and don’t let me open them, CN VIIIGross test of hearing rub hair over ear areaWebber’s and Rinne’s 256HzCN IX and XPalate symmetry/displaced uvula? It goes to the normal side/say “Ah” X nerve palsy if it is abnormalGag reflex (9th = sensory, Xth = motor)Posterior 1/3 taste = 9th nerveSpeaking recurrent laryngeal nerve palsySwallowing ability OK?CN XI (Accessory)

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Percuss – tympani? Dullness? Shifting dullness/ BladderPalpate – tenderness/masses/pulsations/size of liver and spleen/ballot the kidneys/ try for rebound tenderness, Murphy’s sign, appendix tenderness – get pt to lift right leg vertically up to illicit any appendicitis signs also/BladderAuscultate – bowel sounds (borborygmi?), renal and external iliac bruits, friction rubs, venous hum (epigastric)

Lower LimbsNote any oedema, scratch marks, bruising, inguinal lymph nodes, HERNIAS

GenitalsTestes for hypogonadismAsk for the need for a gynaecological examination if masses identified in palpation or suspicion of PID

OTHERDRE, Hernias, Urine analysis for bile, temperature for infection

Shrug shoulders (trapezius)SternomastoidsXIIStick out your tongue note fasciculations and wastingNote any deviation (no deviation in unilateral UMN lesion as there is bilateral innervations. The tongue will deviate to the weaker affected side in unilateral LMN

lesions.

UPPER LIMB EXAM LOWER LIMB EXAMGeneral InspectionPosture/Wasting/Abnormal movements/Skin – neurofibromatosis, herpes zoster, scars, urinary catheter, cutaneous angiomataShake handsInability to relax after contraction = dystrophia myotonicaCheck for drift with arms outstretched and eyes closedUMN – downwardsCerebellar – upwardsLoss of proprioception – any direction driftToneCogwheel rigidityMyotonia (inability to relax after sudden movements)

Check for percussion myotoniaHypotonia

Check by holding arm up and letting it dropCheck tone in wrists and elbows with supination and pronationPower0-5 scale0 = complete paralysis1 = Flicker of contraction possible2 = Movement possible with NO GRAVITY3 = Movement against gravity with no resistance4 = Movement against varying resistance (-, norm, +)5 = Normal powerShoulder – abduction C5/6, adduction C6-8)Elbow – flexion C5/6, extension C7/8Wrist – Flexion / Extension C7/8Fingers – Extension C7/8, Flexion C7/8, Abduction C8/T1, Adduction C8/T1ReflexesBiceps C5/6Triceps C7/8Supinator C5/6Finger jerks C8CoordinationFinger-nose (intention tremor and over pointing = cerebellar disease)DysdiadochokinesisGet pt to lift arms rapidly and then stop suddenly finds hypotonia due to cerebellar diseaseSensationPin PrickSoft touchVibratory sense 128HzJoint position sensePraxisCan you comb your hair for me? Pretend please! Can you pretend to brush your teeth?

Begin by testing GAITInspectFasiculations and muscle wastingUrinary catheter? May indicate MS or spinal cord diseaseFeel muscle bulk of quads and anterior tibial musclesToneRoll the legs (internal/external rotation)Lift abruptly each knee at a timeTest ankles and don’t forget clonusPowerHip – flexion, extension, abduction, adductionKnee – Flexion, ExtensionAnkle – plantar flexion and dorsiflexion, Tarsal joint – eversion and inversionReflexesKnee jerk (L2-4)Ankle jerk (S1-2)Plantar (L5-S2)CoordinationHeel-shinToe to fingerFoot tappingSensationPin PrickLight touchVibratory sense 128HzJoint position sense PraxisCan you kick a ball?

Individual nervesLateral cutaneous nerve of thigh = sensory loss on lateral nerve, if painful it is called meralgia paraestheticaFemoral nerve (L2-4) = weakness of knee extn, absent knee jerk, slight hip flexion weakness, sensory loss to inner thigh and legSciatic nerve (L4-S2) = Foot drop and weak knee flexion, knee jerk intact but ankle and plantar responses absent. Sensation of posterior thigh, lateral and posterior calf, and foot.Common perineal nerve (L4-S1) = supplies anterior and lateral compartment muscles of leg. Test for weakness of dorsiflexion and eversion. Reflexes all intact. Minimal sensory loss over the lateral aspect of the dorsum of the foot. Can be confused with L5 root lesion!

HAEMATOLOGICAL / IMMUNOLOGICAL EXAMINATION EXAMINATION OF THE PREGNANT ABDOMEN

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General InspectionWeight and BMI / Age / Gender / Bruises / Rashes / Racial origin (greek? Thalassaemia)Pallor / Scratch marks (lymphoma) / Jaundice (haemolysis)

HANDSKoilonychia / Digital infarction (cryoglobulinaemia) / Palmar crease pallor / RA / OA / Gouty changes / Look for redness and swelling

ARMS and SKINPetichiae and purpure (petichiae are palpable which suggests underlying vasculitis)Hess test (thrombocytopaenia suspected) – inflate cuff to above diastolic pressure to see if >20 petichiae formEpitrochlear nodes – always pathological if present so always checkAxillary nodes – apical, central, anterior, posterior, arm, supra and infraclavicular

FACEEyes – anaemia / scleral icterus / Mouth – hypertrophic gums seen with immunosuppressive therapy, HIV and monocytic anaemia / Gum bleeding / Atrophic glossitis / Ulcers / Tonsils

NECKLymph nodes – submental, submandibular, preauricular, postauricular, anterior cervical and posterior chains, occipital, supraclavicular

CHEST AND BACKTest for bony tenderness of spine and over sternum, claviclesBreast examination

ABDOMENInspect – distension, scars, bruises, scratch marks, rashesPalpate – masses, liver/spleen, para-aortic nodes (lymphoma)Inspect testicles

LEGSInspect – rashes, bruising, scratch marks, palpable purpure in henoch scholein purpura = BUTTOCKS, signs of peripheral neuropathy and ulcers, pigmentation (DVT related and PVD related)Inguinal nodes

FINAL REMARKSTemperature - ?feverUrinalysis – haematuria in bladder cancer, bile in haemolysisDRE and pelvic examination

GENERAL INSPECTIONBMI, Age, Signs of oedema in fingers and ankles

NEXT...WEIGH THE PATIENTBlood pressurePulseTest for reflexes and clonus

ABDOMENInspection – caesarean scars/previous surgeries/linea nigra/striae gravidarum/shape of uterus and any asymmetry/visible foetal movementPalpation – SPH / Palpate fundus / Palpate each side to assess lie / Palpate lower pole / Assess for presenting part and how many 5ths above the pubic symphysis

“The foetus is in a left longitudinal lie with a cephalic presentation at 4/5 above the pubic symphysis” “The PFH is 36cm consistent with the mother’s 37wks gestation”

FOETAL HEART SOUNDSUSS Doppler (normal is 110-160/180bpm)Good variability is ≥5-25

EXTRASI’d also like to;

Auscultate the lungs for pulmonary oedema in suspected pre-eclampsia Urine test – protein, glucose, WBCs Bloods;

Depending on concerns – ELFTs, FBC, Group and Rh, Rubella, HIV, Hep B and C, CMV, HSV, Varicella, TFTs

USS – dating scan and to assess foetal age and any issues

THYROID EXAMINATION Assessing for suspected malignancyGeneral InspectionPt BMILooks anxious / tired / obvious goiterHandsTemperature / Pulse – AF / Look for onycholysis in ring finger in graves / dru or sweaty skin / Hypercarotenaemia in hypothyroidismTREMOR – do paper testArmsTest for proximal weaknessBPReflexesFaceAsk pt to talk hoarse from goitre?Eye brows – loss of outer 1/3 with hypothyroidismExopthalmus / Proptosis / Lid lag / graves opthalmopathy / conjunctival injection / loss of hair / skin temperature / xanthalasmaNeck Scars for thyroidectomyGoiter assessment – look for swallow and palpate with swallowAuscultation of goitre for bruitPembertons sign for retrosternal goiterPercuss the chest for retrosternal goitreChestCheck for high flow murmurs and pulmonary oedema in lungsCheck for pleural effusionsLegsLook for pre-tibial myxoedema in gravesTest for myopathy and reflexes

Palpate all draining lymph nodes of suspect lumpPalpate all remaining lymph nodesExamine abdomen – especially for hepatosplenomegaly and ascitesFeel the testesRectal examination and pelvic examinationExamine lungsExamine breastsExamine all skin and nails for melanoma

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MSK EXAMINATIONS TO KNOW...

HAND AND WRIST EXAMINATION SPINE EXAMINATIONLOOKLook for asymmetry, scars, swelling, heat and redness, rheumatoid nodules/changes, boutonnieres deformity, heberdens and bouchards nodes, dupytren’s contracture, nail changes, muscle wastingMOVEWrist – flexion, extension, ulnar deviation, radial deviation, supination and pronationFinger – flexion at DIPs, Flexion at MCP, extension of fingers, adduction and abduction of fingersThumb – flexion, extension, abduction, adduction, oppositionSpecial tests – opposition strength, pincer grip and strength, paper tests with thumb adduction and finger adduction, phalens sign and tinels tap for medial nerveFEEL Feel base of first MCP (most common place for OA), snuff box for scaphoid, all joints

LOOKGenerally – scars, deformity, rashesCervical lordosisThoracic kyphosis or excessive kyphosis or loss of Lumbar lordosis or loss of lumbar lordosisAsk patient to walk – observe gaitMOVECervical – flex, extend, rotation, lateral flexionThoracic - rotationLumbar – flexion, extension, lateral flexion FEELSpinous processes, interspinous ligaments, paravertebral muscles + facet joints, sacroiliac jointBony tenderness for mets

Neurovascular examination

ELBOW EXAMINATION HIP EXAMINATIONLOOKSwelling and effusions, redness, rashes, gouty tophi, rheumatoid nodules, scars, muscle wastingMOVEFlexion to 150˚, Extension, Supination and pronationSpecial tests – resisted flexion wrist for medial epicondylitis and resisted extension for lateral epicondylitisFEELFeel around for joint effusionsFeel epicondyles for epicondylitis

LOOKGait – high stepping, waddling, ataxic, trendelenberg, scissors gait, antalgic gait, varus/valgus deformityAsymmetry, scars Trendelenbergs test whilst standingLying down – look at leg shortening, measure from medial malleolus to the ASIS for leg length, look for fixed flexion deformityMOVEFlexion and straight leg raise (sciatic nerve)Extension and L2-4 femoral nerve stretch testAbduction and AdductionInternal and external rotationSlump test (sciatic nerve) – slump, flexed neck and dorsiflexionFABERS test = pain in back indicates SIJ pathology or lumbar spine pathology, pain in the groin is relating to iliopsoas hip flexor pathologyPOSH test for SacroiliitisTest for fixed flexion deformity = Thomas’ test (flex one leg with hand under spine and if other leg moves = + test)FEELBony prominences, greater trochanter, inguinal ligament, Muscles – iliopspoas, gluteus min/med and maximusSacroiliac tenderness

Finish by saying you’d like to examine the spine and knees and do a full neurovascular examination

SHOULDER EXAMINATION KNEE EXAMINATIONLOOKCompare shoulders – side, back and frontLook for asymmetry, scars, swelling and deformity, alignment, rashes and skin changes, winging of scapula, muscle wasting or loss of usual shape, squaring off of the shoulder or scapula muscle lossMOVEFlexion, Extension, Abduction, Adduction, Internal rotation and External rotationPassive movements too please...Special tests – shoulder apprehension test, subscapularis resisted adduction test, empty can test for supraspinatousPush hands against wall = winging of scapula

LOOKStanding – valgus / varus deformityWalking – antalgic gait, foot drop etcLook for pes planus (flat feet) or pes cavus (high arch) of feet as wellSquatting – note any crepitus or pain/difficultyJoint – look for scars, deformity, asymmetry, muscle wasting esp of quads, effusions, bakers cysts, redness and swelling, feel for warmthMOVEActive and Passive;

Flexion Extension

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Passive abduction pain between 10 and 120 degrees = painful arcImpingement syndrome = passive abduction of arm, Neers test = full flexion and then internally rotate, Hawkins manoeuvre = flexion at 90˚ and then internally rotateAC joint test = arms across chest in a crossSupraspinatous = empty can testScapula lift off test = subscapularisResisted external rotation = infraspinatous and teres minorAprehension Test = external rotation and abductionFEELTemperature of the jointsBony landmarks – SC, AC, Glenohumeral, bicipiral groove, Scapula spine and muscles of scapula/shoulder = supraspinatous, infraspinatous, teres minor and trapeziusCoracoid process and biceps tendonSubacromial bursa with arm extendedPalpate axilla alsoNeurovascular testingExamine the cervical spine as it often refers to shoulder

Internal and External rotation – minimalSpecific tests

Valgus and varus stress tests for collateral ligs Anterior draw test for ACL Posterior draw test for PCL Lochman’s test for ACL McMurrays test for meniscal tear Apley’s grinding test for meniscal injury Patella apprehension test

FEELCollateral ligamentsMeniscal areas of tibiaPatella and tibial tuberosityFeel for effusions (rub medial side first) and check patella tap testPalpate posterior area for fullness (bakers cyst)Palpate pre and post patella bursa and bursa in the pesanserine area (bursa)

Finally – examine ankle and hip and do a full neurovascular assessmentFOOT AND ANKLE EXAMINATIONLOOKSwelling, Asymmetry, Deformity, Bruises, ScarsNail changes, Skin rashes, hallux valgus, clawing of toes, hammer toes, callous formation, look at shoes for asymmetrical wear and tearArchilles tendonStanding – valgus or varus deformity. Flat feet or high arches.GAIT

MOVE – do active and passive movementsInversion and Eversion – subtalar jointDorsiflexion and plantar flexion at ankle jointDorsiflexion and plantar flexion of big toeMidtarsal and talar movements can be assessed passively

FEELMTP jointsTarsal joints esp head of 5th metatarsalSubtalar jointsNavicular bonePosteriorly on tibia and fibula malleoliThompsons test for archilles ruptureAnterior draw test of ankle for rupture of anterior TFLDo pulses and feel temperature of feet

Finish by saying full neurovascular examination and assessing the knees/hip as well

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