1

CLINICAL EXAMINATION

ENT HEAD AND NECK

Examination of theThyroid

NEUROLOGIC EXAMINATION
Cranial Nerve Examination
- Inspection: scar marks, asymmetry of face, eyes,
pupils, wasting
- I ask patient to smell
- II PEARL, Funduscopy, VA, pinhole test, visual
fields,
- III, IV, VI ptosis; presence of asymmetry of eyes and
pupils; extraocular movements; accommodation
- V sensation (ophthalmic, maxillary, and mandibular)
and motor (clench teeth - masseter; open mouth and
push to close pterygoid muscles; if weakened jaw
deviates to affected side); corneal reflex; jaw jerk
(UMN)
- VII close eyes and dont let me open them, smile,
wrinkle forehead, puff up cheeks
- VIII whisper test; rinne test and weber (256)
- IX and X hoarseness; cough; ask to sip water to
check problems with swallowing; Gag reflex and uvula
- XI raise shoulder and SCM
- XII tongue
TIA Examination
- Face: asymmetry of face, ptosis, eyes/pupil of equal
size, redness/swelling; PEARL; ophthalmoplegia;
accommodation; funduscopy
- JVP, carotid pulse and bruit
- Upper/Lower limb neurologic examination
Neurological Examination of the Upper Limb
- Inspection: signs of head injury, facial asymmetry,
ptosis, muscle wasting and fasciculation
- Palpate muscles for tenderness, Pronator drift
(UMN/cerebellar lesion), tremors,
- Tone
- Power (shoulder grasp, biceps and triceps power,
flexion and extension of wrist, grasp, flexion and
extension of fingers; adduction and abduction of
fingers
- Reflexes: biceps, triceps, brachioradialis
- Sensation
- Vibration and Proprioception
- Finger-to-nose test and alternating movements
(dysdiadochokinesia)
Neurological Examination of the Lower Limb
- Inspection: wasting of muscles, tremors,
fasciculations, surgery marks, deformity
- Gait assessment: observe for limping
- Walk on heels: L5
- Walk on toes: S1
- Squatting
- Romberg test
- Heel-Toe Walking
- Palpation for tenderness of muscles
- Power (hip flexion and extension, knee flexion and
extension, adduction, abduction, inversion, eversion,
plantar flexion, dorsiflexion)
- Reflexes (knee, ankle, babinski, clonus)
- Sensation
- Vibration and Proprioception
- Cerebellar: Heel-to-shin, foot tapping test

IF you feel any pain or discomfort during the

examination, please let me know and I will stop. I will
be gentle.
Ask patient to remove clothing and wash hands!
Inspection:
o General appearance: appropriate dressed
for the weather
hyperthyroidism:
anxious/restless/agitated, weight
loss
hypothyroidism:
depressed/sad/dull/apathic/anxiou
s/restless/agitated/ hoarse
voice/sluggish
o Neck: look for swelling, scar marks, dilated
veins (retrosternal extension), redness
(thyroiditis)
o Ask patient to sip water and look for
movement during deglutition; check border;
ask patient to protrude tongue
MASS: 4S (site, size, shape, suface), 4C (color,
consistency, contour, compressibility), 3T
(temperature, tenderness, transillumination), 2F
Fluctuation, Fixation), pulsatile, reducible, signs of
inflammation
Palpation (from behind)
o Palpate both lobes and isthmus
o Sip of water and look for all characteristics
of the mass (soft: adenoma; cystic: cyst;
firm: goiter; hard: cancer; tenderness:
thyroiditis; immobile: cancer); palpable thrill
o Cervical lymph nodes (submental
submandibular preauricular
postauricular anterior cervical posterior
cervical occipital)
o Look at position of trachea from front (if
displaced may be retrosternal extension)
Percussion: from upper part of manubrium from one
side to the other (change from resonant to dull
indicates restrosternal goiter)
Auscultation: listen for each lobe for any bruit
(increased blood supply due to hyperthyroidism)
Pemberton sign: ask patient to lift both arms as high
as possible and look for plethora, cyanosis, respiratory
distress, or neck vein distention signifies thyroid
gland is closing the thoracic inlet and impedes venous
flow to the heart
Hands, nails and skin
o Hyperthyroidism: warm, sweaty, palmar
erythema; onycholysis (nail separating from
bed); tremors; shiny and smooth
o Hypothyroidism: cold, dry, swollen, thick
skin, anemia; dry and coarse
Pulse for rate and rhythm and Blood pressure
Reflexes
o Hyperthyroidism: brisk reflexes
o Hypothyroidism: delayed relaxation
Proximal myopathy: hyperthyroidism
Face
o Hyperthyroidism: fine shiny hair, proptosis,
lid lag and retraction, chemosis (edema of
conjunctiva), conjunctivitis, corneal
ulceration, ophthalmoplegia

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Hypothyroidism: brittle, dry and coarse,
alopecia, loss of eyebrows, periorbital
edema, facial puffiness, xanthelasma (lipid
deposits over the lower eyelids), swollen
tongue
Other signs (Hypocalcemia):
o Schvostek: twitching of facial muscles upon
tapping of the facial nerve along the angle of
the mandible
o Trousseau: flexion of wrist and MCP joints
upon inflating the BP cuff above systolic.
Chest: gynecomastia in hyperthyroidism; pleural
effusion (hypothyroidism)
CVS: hyperdynamic circulation (arrhythmia and
cardiac failure) and systolic flow murmurs; pericardial
effusion (hypothyroidism)
Myopathy: sit and stand hyperthyroidism
Legs: pretibial myxedema (bilateral firm, elevated,
dermal nodules on the shin, may be of different colors
hyperthyroidism
o

Examination of a Patient with Facial Trauma

-

Ask for consent

Inspection (Look): there is a bruise on the left side of
the cheek; no obvious asymmetry or swelling is noted;
no obvious fracturers; in the eyes there is no raccoon
eyes (purplish discoloration around the eyes: orbital
floor fracture) or any swelling or redness; on the nose
there is no obvious fracture; no obvious drainage of
fluid. Ask patient to open the mouth and look for any
loss of tooth or injury. On the ears look for any injury,
bleeding, or fluid. There is no battle sign (discoloration
of mastoid due to basal skull fracture) On the neck
and head, there is no obvious swellings, bumps,
deformities
Feel: feel surrounding area for fracture or tenderness;
take torch to look for pupillary light reflex; do EOM
(diplopia); ask for funduscopy and visual acuity; take
pin to check for sensation; clench teeth; corneal reflex;
close eyes and do not let patient open them; open
teeth and smile for me; feel head for any injury or
swelling; feel cervical spine and paraspinal muslces to
look for tenderness;
Move: do ROM of neck;

Pleiomorphic Adenoma
Case: A middle-aged man comes in to your GP clinic with a
swelling on the left side of his face just above the angle of his
jaw between the mastoid and mandible. A picture of the swelling
is provided.
Task
a.
b.

c.

History (lump x 5 years noticed when he was shaving;

slowly growing, not painful, came in due to cosmetic
reasons, + smoker x1/2 pack)
Physical examination (3x3, irregular, firm, nontender,
rounded/bosselated, well-circumscribed, no punctum,
redness, discharge or scar marks, no LN enlargement,
facial nerve examination)
Diagnosis and management

History
- Can you tell me more about it? When? Is it growing
suddenly or slowly? Painful or not painful? Does it
move when you feel it? It is firm or hard when you feel
it? Any ulceration, infection or bleeding from this site?
Any other lumps and bumps in the body? Any weight
loss or change in appetite? Did you notice any

asymmetry of the face? Any disturbance in function of

your face? Any change in taste sensation? Any
problems with swallowing, hearing or breathing?
Hoarseness? do you have any pain or swelling in the
gum while chewing?
How is your general health?
PMHx of cancer or radiation therapy?
FHx of cancer
SADMA?

Physical examination
- General appearance
- Vital signs
- ENT: Inspection, palpation (site, size, shape, surface,
contour, consistency, compressibility, temperature,
tenderness, transillumination, fixation, fluctuation,
reducible, pulsatile, signs of inflammation, discharge,
ulceration, vascularity), Lymph nodes (submandibular,
submental, anterior and posterior auricular, occipital,
anterior and deep cervical LN), Facial nerve testing:
asymmetry, close eyes and dont allow to open them,
smile, clench teeth, Do check oral cavity using mouth
and torch (dental problem or ulcers of mouth and
tongue); parotid duct:: palpate from inside of the
mouth and check for discharge and salivary stone
Diagnosis and Management
- For examiner: We are presented with a middle-aged
man who presents with a long-standing mass on the
face which is suggestive of a parotid enlargement. On
examination, the mass is noted to be wellcircumscribed firm mass without signs of facial nerve
involvement which is highly suggestive of a benign
tumor called pleiomorphic adenoma.
-

For patient: From history and examination you have a

condition called pleiomorphic adenoma of the parotid
gland. Let me assure that it is a benign swelling and to
further confirm it, I will refer you to the surgeon. He will
do a CT scan or MRI to see the overall dimension and
tissue invasion and FNAC to determine whether the
tumor is benign or malignant.
Differential Diagnosis: Warthins tumor, Sebaceous
cyst, lymphoma, metastasis from primary growth,
parotid abscess, lipoma, pre-auricular adenoma,
Chronic parotitis
Once confirmed the surgeon will remove it through a
procedure called Superficial parotidectomy. In this
surgery, the lump is removed and the facial nerve is
preserved. Complications include: hemorrhage,
anesthetic complications (aspiration), facial nerve
injury, salivary fistula, recurrence
Reading materials, refer and review.
For cancer: Total parotidectomy or block neck
dissection with radiotherapy

RESPIRATORY SYSTEM EXAMINATION

Examination of the Respiratory System
-

Consent
Inspection: sitting comfortably on the bed and does
not appear to be SOB, conscious and alert, not
cyanosed, not attached to oxygen, no medications, or
IV lines. He does not appear cachectic.
Hands: cyanosis, clubbing, nicotine stains, test
patient's resistance to adduction (brachial plexus
involvement in pancoast/apical lung tumor), press
wrist and note tenderness (hypertrophic pulmonary
osteoarthropathy - results from periosteal

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inflammation secondary to pancoast tumor), pulse and
RR, wrist extension for 30 mins and look for flapping
tremors for CO retention
-

Face: pallor, jaundice, Horner syndrome, check for

tenderness of maxillary and frontal sinuses, nose for
swelling, polyps, and deviated nasal septum, open
mouth to check for focus of infection, speak a
sentence for hoarseness, ask px to cough for bovine
cough

Do Peak expiratory flow rate (PEFR)

o F: 400L/min and M: 600L/min

CARDIOVASCULAR AND PERIPHERAL VASCULAR

Cardiovascular Examination
Position patient to 45 degrees and expose neck and
chest up to lower abdomen
General inspection: lying comfortably at 45 degrees,
not cyanosed and dyspneic, not cachectic (cardiac
cachexia weight loss due to heart failure), no
features of down, marfan, turner syndrome, not
attached to oxygen, ECG monitor or drugs on the side
of the patient
Hands/nails: check for cyanosis, splinter
hemorrhages, clubbing, CRT, nicotine stains, palmar
erythema, Janeway lesions (painless red macular
patches on palms), Osler nodes (tender nodules on
the pulp of the fingers), anemia/pallor, tendon
xathomas
Arms: Radial artery pulse for rate and rhythm,
compare both pulses for Radioradial delay (subclavian
artery stenosis) or Radiofemoral delay (COA),
collapse impulse (AR), BP (sitting and standing)
Face: anemia, jaundice, xanthelasma, malar flush
(SLE, MS, pulmonary stenosis), tongue and lip for
central cyanosis, high-arched palate (marfan
syndrome), petechia, telangiectasia (IE),
stomatitis/gingivitis;
Neck: carotid pulse, JVP (patient at 45 degrees: use 2
ruler: 1 ruler straight up at manubrio-sternal angle
then measure in cm add 5cm >8cm is raised
JVP)
Precordium:
o Inspection: scars (middle
sternotomy/thoracotomy), pacemaker
(below clavicle, subcutaneous),
kyphoscoliosis, pulsations, deformity
o Palpation: apex beat (5th mleft ICS, 1cm
medial to the midclavicular line; check
whether
forceful/tapping/displaced/diffuse/parasterna
l impulse), heave (palm), thrill at base of
heart (pulmonary and aortic area using
fingers)

Auscultation: bell of stethoscope at apex

beat;

Neck: Lymph node and trachea, JVP (if indicated)

Chest
Inspection: pectus carinatum/excavatum, deformities,
scars, radiation marks, erythema and signs of
inflammation, tattoos, barrel-shaped chest,
kyphoscoliosis, spine central
Palpation: check chest expansion (breathe in and out
by mouth): upper lobe expansion (equal rising of
clavicles), middle and lower lobe: thumbs should
move at least 5cm, sacral edema, tactile fremitus (with
hands over chest)
Percussion: supraclavicular area
Auscultation: air entry, added sounds, vocal fremitus
Examine anterior chest as well
-

MS: mid-diastolic (bell); ask

patient to turn on left side feel
hand for palpable thrill; auscultate
murmur heard clearly;
MR: pansystolic (diaphragm);
radiates to axilla;
AS: ejection systolic murmur;
Neck;
AR: early diastolic murmur; ask
patient to lean forward; then
breathe in and out hand and
auscultate
Systolic murmurs: radiate
Diastolic murmurs: accentuated by
change of position
Dynamic auscultation: Pinch nose
and ask patient to breathe in and
try to breath out thru the ears
valsalva auscultate at left
sternal edge for systolic murmur of
HOCM

Back:
o

Inspect: scars, deformity, bamboo spine

(PR)
o Feel: sacral edema, pleural effusion
o Auscultation: crepitation, pleural effusion (no
breath sound)
o Radiofemoral delay: listen to scapula
COA
Abdomen: lying flat with one pillow
o Abdomino-jugular reflex
o Palpate liver and spleen
o Ascites
o Aortic aneursym
Lower limbs for edema, pulse
Urine dipstick, funduscopic, hematuria, HTN changes,
Roth spots in infective endocarditis

Murmurs:
MS: normal pulse, reduce in volume
MR: pounding pulse
AS: slow-rising pulse
AR: collapse pulse
Systolic murmur at aortic area (DDx)
AS radiate to carotid
Aortic Sclerosis (doesnt radiate)
HOCM functional systolic murmur
Pregnancy
Thyrotoxicosis
Fever
Anemia
Main causes of AS
Increased age
Congenital bicuspid valve
Main causes of MR
Rheumatic fever
MVP/rupture of chordate tendinae
MI
Infective endocarditis
Dilated cardiomyopathy

Examination of the Lower Extremities

-

Introduce yourself. I understand from your notes that

youre having pain on the leg. My task is to do the
physical examination. During this examination, I will
look and will be palpating/feeling some parts of the
leg. I will also need to listen to some of the vessels on
your leg with the use of my stethoscope.
AT this moment I would like to ask you if you have any
pain. I will ask for your permission to expose your
thighs and legs (usually up to the nipple area but
cover abdomen and expose only when required).
While you undress I would just like to wash my hands.
Inspection:
o Abdomen: check for visible pulsation (AAA
left of the midline), scar marks;
o Groin: pulsation, scar marks;
o thigh and legs: muscle wasting, joint
deformities, atrophy of the skin, loss of hair,
change of color of skin, shiny skin;
o feet: obvious deformity, ulcers (include toes,
raise legs, under heels), hallus valgus;
discoloration/cyanosis/blackening of nails;
look for signs of amputation in toes; obvious
edema and signs of inflammation
Palpation: check for capillary refill time (<3secs); feel
for temperature (with dorsum of hands); pinch shins
for any edema; feel the PULSES (dorsalis pedis,
posterior tibial, popliteal, femoral, abdomen);
Auscultation: listen for bruits (AAA); both sides (renal)
then femoral; Buerger test: raise your legs 45 deg for
10-15 seconds (if there is pallor suspect PVD) then I
would like you to sit down and hang your legs from the
edge of the bed (check for cyanosis or dusky red)
What is the ABI?

Examination
Inspection:
o Distribution:
Below the femoral vein in the groin
to medial side of the thigh to lower
leg saphenous vein
Back of leg to calf area short
saphenous vein
o Signs of inflammation, cutaneous venous
flares, pigmentation, edema,
lipodermatosclerosis, dermatitis/eczema,
venous ulcers, loss of hair, atrophy of skin,
color change of the skin (deep blue, black,
purple), venous impulse at saphenofemoral
junction
Palpation
o Hard: thrombosis; tender: thrombophlebitis
o Temperature
o cough impulse
Place fingers over line of vein
immediately below the fossa
ovalis (saphenofemoral
junction) ask patient to cough

Patient lies down and leg is elevated to 45

deg. To empty the veins
o Apply torniquet with sufficient pressure to
prevent reflux over the upper thigh
o Patient stands
o Long saphenous system will remain
collapsed if there are no incompetent veins
below the level of fossa ovalis. When
pressure is released, the vein will fill rapidly
if the valve at the saphenofemoral junction is
incompetent
o Doubly POSITIVE: is when veins fill rapidly
before the pressure is released and then
with a rush when released (coexisting
incompetent perforators and long
saphenous vein)
Perthes Test
o Put tourniquet on mid-thigh ask patient to
stand and up and down on the toes for 10x
after releasing some of the blood.
o Collapsed veins are normal
o If superficial veins increase in prominence or
pain deep vein are occluded or
perforators are incompetent
o If veins are unusual in distribution
exclude pelvic neoplasm/mass that is
obstructing the deep vein system
Confirmatory: venous Doppler ultrasound
o

Examination of Varicose Veins (Case 148R8)

Risk factors
Female sex
Family history
Pregnancy
Multiparity
Age
Occupation
Diet (low fiber)

impulse or thrill will be felt

expanding and travelling down the
long saphenous vein
Marked dilated long saphenous
vein in fossa ovalis (saphena
varix) will confirm incompetence
disappearas when patient lies
down
Special tests: Trendelenburg test (checks the level of
incompetence) long saphenous vein, short
saphenous vein and perforators

Management
Refer for Doppler ultrasound for accurate diagnosis
Use supportive stockings (apply in the morning before
standing out of the bed)
Avoid scratching skin over the veins
Sit with legs on a foot stool
Maintain ideal weight
Eat high fiber diet
Treatment options
o Sclerotherapy (use a small volume of
sclerosing agent particularly below the
knee)
o Surgical ligation and stripping remove
obvious varicosities and strip perforators
Complications
Superficial thrombophlebitis
Skin eczema
Skin ulceration
Bleeding
Calcification
Marjolin ulcer (SCC)

EXAMINATION OF THE ABDOMEN

Recent hematemesis in a 50-year-old man (Chronic Liver
Disease)
Case (Condition 70): You are an intern in the ED and a 50-yearold male having had hematemesis for about 500ml of fresh
blood 2 hours ago accompanied by transient feeling of
lightheadedness and sweating. The patient is alcoholic and
likely to have chronic liver disease on the basis of history that
you have taken.

Perforated Peptic Ulcer

Case: You are an HMO in ED and a middle-aged man comes to
you because of acute abdominal pain. He had low back pain last
week and was prescribed NSAIDs. He is a smoker and an
alcoholic beverage drinker.
Task
a.
b.

Focused examination
Diagnosis and management

Task
a
b
c
d

Perform relevant and focused PE of the patient

Explain actions and what you are looking for to
examiner
Describe findings as you proceed
No need to take further history

Physical examination
Is my patient hemodynamically stable
Consent
Exposure: midchest to symphysis pubis
Inspection:
o General appearance: Patient lying
comfortably. Abdomen moving with
respiration. He is not cachectic. There is no
obvious jaundice or pigmentation. He is well
oriented. IV drug marks
o Hands: clubbing, cyanosis, leukonychia,
pallor, CRT, palmar erythema, dupuytren
contractures
o Raise hands flapping tremor/asterixis (2030 seconds)
o Arm: Spider nevi, bruising/petechia, scratch
marks, IV drug marks, tattooing or body
piercing
o Face: anemia and jaundice, KayserFleischer rings, parotid gland enlargement,
fetor hepaticus, flushing/congestion of the
face; Mouth: stomatitis, gingivitis,
ulcerations, telangiectasias
o Lymph nodes: cervical, axillary, inguinal
o Chest: spider nevi and gynecomastia
Abdomen
o Inspection: distention, caput medusa, visible
pulsations, visible peristalsis, striae,
bruising, hernia orifices
o Inspect at level of tummy: ask patient to
breathe in and out through the mouth look
for visible masses
o Palpation: Ask if patient has pain anywhere
in the stomach; Relax and breathe in and
out; mass or tenderness on superficial
palpation; deep palpation; palpate liver
o Liver span: from midclavicular line (Normal:
6-12)
o Spleen
o Percussion: shifting dullness for ascites
(percuss from right towards left side)
o Auscultation: bowel sounds and venous
hum (between umbilicus and xiphisternum)
o Testicular atrophy
o Scratch marks in legs and edema;
sensations
o DRE!!!!

Case 2: John aged 45 years presents to ED of a local hospital

where you are working as HMO 1. He had severe abdominal
pain since this morning which is getting worse now. He had
vomited once but now had only dry retching. He took panadol
and neurofen but with no relief. He had not experienced such
pain in the past. He is a smoker and drinks moderate amount of
alcohol on weekends.
Task
a.
b.
c.

History (started after breakfast, 10-11 in severity,

epigastric, takes panadol and neurofen for knee pain)
Physical examination (unwell, tired, BMI 24, PR:
120/min, mild dehydration, rebound, guarding and
rigidity)
Differential diagnosis and management

Examination
Is my patient hemodynamically stable
General appearance: lying on bed, unwell and in pain.
offer painkiller (morphine 2.5mg IV + metoclopramide)
Vital signs (BP with postural drop)
Inspection:
o Abdomen not moving with respiration
o General inspection of abdomen: scars,
distention, jaundice, pigmentation
Palpation:
o Where do you feel the pain?
o Superficial palpation tenderness
o Guarding, boardlike rigidity, rebound
tenderness on deep palpation
Auscultation: Bowel sounds
Hernia orifices
DRE
Investigations
FBE, ESR/CRP, blood group and crossmatching
U&CE, LFTs, BSL,
Amylase and lipase
Erect CXR (free gas under diaphragm) and Xray
of abdomen (supine and upright)
Differential Diagnosis
Perforated viscus
Acute pancreatitis
Mesenteric ischemia
Acute cholecystitis
AMI
If female: Ectopic pregnancy, ovarian cyst
rupture/torsion; PID; miscarriage
Management
Admit and call surgical registrar because it is an acute
abdomen most likely due to peptic ulcer
Pass 2 IV line and start fluids for full resuscitation
Pass NGT to decompress stomach
NPO
Insert indwelling catheter to monitor I&O
Start IV antibiotics

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-

ask patient to cough if sac hits

finger indirect inguinal hernia

Surgery (Exploratory laparotomy)

Examination of an Inguinal Hernia

Case: You are a GP and your next patient is a 40-year-old
laborer. 2 weeks ago, he felt pain in his right groin after heavy
lifting at work and a week later, noticed a lump in the groin which
was not there before.
Task
a.
b.

Perform focused physical examination

Diagnosis and management

Differential Diangosis
Hernia
Lymph node
Undescended testes
Lipmoma
Hydrocele
Saphenovarix
Aneurysm
Neuroma
Examination
Consent
Do you have any pain in this area?
On standing:
o Inspection: site of swelling (whether medial
or lateral to pubic tubercle), size, shape,
color of underlying skin, and contour, signs
of inflammation. scar marks
o
o
o
-

Scrotum (extent of hernia; varicocele and

visible pulsation for saphenovarix)
Ask patient to reduce swelling, look at other
side then cough
Palpate the scrotum (can get above the
swelling: hydrocele, epididymal cyst, lipoma,
varicocele testicular swellings)

On lying:
o Check if swelling is reducible then check for
cough impulse; borders, temperature,
tenderness; palpate testes, epididymis and
spermatic cord
o Determine whether femoral or inguinal:
Femoral: if it lies 4 cm below and
4 cm lateral to pubic tubercle
Direct inguinal: above pubic
tubercle and inguinal ligament; 1
cm above pubic tubercle; lies
medial to the inferior epigastric
vessel; sac lies behind spermatic
cord
Indirect inguinal: above pubic
tubercle; lateral side of inferior
epigastric vessel; sac lies within
the spermatic cord so it can
descend to the testes
o

Ring occlusion test

Occlude deep inguinal ring and
ask patient to cough if its
coming out direct inguinal
hernia release pressure again
then hernia comes out direct
inguinal hernia
Trace finger into spermatic cord
into superficial inguinal ring and

Three finger test

Put index, middle and ring fingers
in the 3 openings: one finger at
4cm above and below the pubic
tubercle, other finger at the DIR
and SIR ask patient to cough
where you feel the impulse
then diagnostic
o Palpate the LN, femoral pulse
Describe hernia to examiner: femoral/inguinal,
reducible/irreducible, direct/indirect
o

Management
Keep an ideal weight
Adjust diet to avoid constipation
Avoid activities that increase intra-abdominal pressure
(heavy lifting, straining and coughing)
Avoid smoking
Referral for surgical consultation. Done usually by
laparoscopic surgery
Complications: infection, bleeding, anesthesia
complications, swelling, damage to nearby organs
(inferior epigastric vessels or inguinal nerves),
recurrence
MUSCULOSKELETAL EXAMINATION OF THE BACK
Examination of Low back
Case: A patient presented to your GP clinic complaining of back
pain.
Task
a.

Perform physical examination of the low back

Inspection: walk on heel, trendelenberg,

Palpation: spinal and paraspinal, greater trochanter,

Red flags for back pain

- Incontinence
- Perianal area numbness
- Loss of rectal tone
Examination
- Inspection: Hairy patch on the back (spina bifida), caf
au lait spots, stigmata of neurocutaneous disease,
muscle wasting or erythema, extended lordosis,
kyphosis, scoliosis, equal leg length, hip and shoulder
length level
- Assess gait (normal phases of walking without
limping, walking on heels, toes, squat (proximal bulk
of muscles)
- Palpation: with two thumb, palpate for spinal
tenderness, sacroiliac joints, iliac crest, greater
trochanter, ischial tuberosities, ASIS, PSIS
- ROM: flexion, extension, lateral flexion, lateral
rotation; Trendelenburg test
- Schoberg test: 10 cm above and 5 cm below the
dimple of venus and ask patient to touch toes
should be >20cm
- Ask patient to sit at edge of the bed and test reflexes
(ankle and knee, clonus and babinski); hip flexion
against resistance, then sensory levels
- ROM of hip: hip flexion with knee extended - 90, and
with knee flexed 135, Internal and external rotation

(look at position of patella), flexion and extension of

knee, inversion/eversion and flexion/extension of foot,
dorsiflexion and plantar flexion of great toe, extension
of hip;
Power of hip and knee against resistance

Modified Straight leg-raising Test (L4-S1) tests

root tension L3-4, L4-5, L5-S1 passively lift the leg
while the patient is supine to maximum he can
tolerate, raise the leg to just below the level and
dorsiflex the foot
Slump Test: patient at the edge of the bed and
slumping and bed head forward to maximum, lift up
head as if doing SLR test, release leg until pain
disappears, and put pressure by putting dorsiflexion,
release neck and dorsiflexion
Clinical Features
Weakness of Iliopsoas muscle (Hip flexion)
Loss of sensation over the thigh and the lower part of
the groin
Reflex: None
Weakness of quadriceps (Knee extension)
Loss of sensation over the patella
Reflex: Knee jerk
Weakness of quadriceps and inversion at subtalar
(Ankle dorsiflexion and cannot walk on the heel)
Reflex: Knee
Extensor hallucis and digitorum longus (Great toe
dorsiflexion and long extensors and everters)
Reflex: None

L2

L3
L4
L5

S1

Management of axillary nerve injury

- In many cases, spontaneous resolution happens
spontaneously and no treatment is needed. It may
take as long as one year.
- If there is any pain, we can give you medication such
as paracetamol in mild pain or if severe/stabbing pain,
other medications such as gabapentin or TCAs can
also be given.
- If not controlled refer to surgery and surgical options
include nerve grafting/reconstruction.
- Refer to physiotherapy to regain muscle strength and
function of nerve.
Examination of the Hand
-

Flexor hallucis and digitorum longus and tendon

Achilles: weakness of Plantar flexion and foot
eversion (Toe walking)
Reflex: Ankle Jerk
Do PR

MUSCULOSKELETAL EXAMINATION OF UPPER LIMBS

Examination of the Shoulder
Book Case:
Consent
Inspection: check for symmetry; check joints both
shoulders are equal; contour of muscles; no muscle
atrophy; bone, muscle, skin and joint; comment on
neck (neurocutaneous stigmata of associated disease,
bruise, deformities, erythema, neck contour is fine),
temperature is equal, musculoskeletral structures look
in place.
Injury to circumflex nerve if there is shaving of deltoid
Palpation: both clavicles, acromioclavicular joint,
bursa, bicipital tendon, suprasinous muscles, midline
and paraspinal areas and infraspinatus, examine
police patch (circumflex nerve), compare pulse,
Check full ROM: flexion and extension of shoulder
joint, abduction to glenohumeral joint, scapula sliding
over thoracic cage, adduction to 0 and across the
body, internal and external rotation, touch tip of
scapula and scratch thumb between scapula
(combined adduction and internal rotation) then
combined abduction and external rotation, then
circumduction
Stool: passive movement
Test power of muscles: resists hands on biceps (full
flexion and extension); do chicken wings
(abduction/adduction); full external/internal rotation
Pulses!

Neurocutaneous structures: use pin and cotton

Throw a ball: apprehension test: impending
dislocation/subluxation/joint unstable if positive

Joints, Pulse, Nerves, Muscles and Tendons!!!

If with trauma: Pulse, nerve function, tendons, joint,
muscle
If rheumatological examination: joint,
tendons/nerves, muscles, pulse
Inspection: nails psoriatic nails (pitting,
onycholysis, hyperkeratosis), subluxation, muscles,
shiny, tighetened skin, thickening of tendons,
erythema, clubbing, deformity of small joints of the
hand (phalanges, MCP or wrist joint), nodules on the
level of elbow swelling, signs of inflammation,
deformity, no muscle wasting or thickening of
hypothenar or thenar muscles, pallor, dupuytren
contracture
o Radial deviation of wrist
o Z deformity thumb flexion of MCP and
extension of PIP (RA)
o Boutonierre deformity flexion of PIP,
extension of DIP (RA)
o Swan neck deformity flexion of DIP and
extension of PIP (RA)
o Heberden DIP (OA)
o Bouchard nodes PIP (OA)
o Sausage-shaped fingers telescoping of
fingers (psoriasis and scleroderma)
Palpation: temperature; elbow, radius, ulna, lower end
of the ulnar styloid processes with 2nd finger,
(denotes RA especially radial styloid and
associated with de Quervain tenosynovitis, severe
OA), wrist and bones of the hand (with thumb), press
from the side and up to detect for any effusion,
crepitation, dupuyren contracture, wasting of
thenar/hypothenar muscles, radial pulse, CRT,
sensation
ROM (Active then passive); open and close hand to
check for crepitus/tenosynovitis
o Elbow: flexion and extension
o Wrist: flexion, extension, lateral and medial
deviation, supination and pronation; degree
of flexion and extension
o Thumb: flexion, extension, adduction,
abduction, opposition
o Hand: abduction and adduction
Power
Nerve Tests:
o Pin touch test: median nerve
o Crush finger with thumb: ulnar nerve
o Full extension of wrist: radial nerve
o Fromens test
Vibration and Proprioception: may avoid

8
-

Carpal tunnel
o Phalen test
o Tinnel
o Finkelstein

Functions of the hand

o Grip strength
o Key hole test
o Comb hair
o Write name
o Undo buttons

Other features of RA
Skin: rheumatoid nodules
Head: scleritis in eyes
Lungs: nodules, fibrosis, Caplan syndrome
(pneumoconiosis)
Heart: pericarditis
Abdomen: splenomegaly
Hematologic: neutropenia (felty syndrome = RA +
neutropenia + splenomegaly), anemia

Osteoarthritis
Usually carpometacarpophalangeal and DIP
MUSCULOSKELETAL EXAMINATION OF THE LOWER
EXTREMITY

Examination of the Hip (Trochanteric Bursitis)

Case: A 45-year-old female complained of pain in the right outer
hip that travels down to her legs since last week.

Task

a.
b.

Examine the patient

Diagnosis and management

Features:
Inflammation of bursitis or tendinopathy of the gluteus
medius tendon
Common in patients on sports or gardening, increased
weight/BMI
Pain around lateral aspect of hip traveling down the
leg
Trendelenburg test may be positive
Female >45-50
Tenderness of the greater trochanter and/or pain
on abduction
Treatment: NSAIDS, RICE, strengthening exercises,
injection therapy
Differential Diagnosis
Avascular necrosis of femoral head
Osteoarthritis of the hip
Lumbar spine radiculopathy
Iliopsoas tendinitis (flexors of the hip) pain on
stretching of the hip flexor or resisted hip flexion
Examination
Expose from waist down
Assess gait (limping), walk on heels (L5) then toes
(S1); squat and stand;
Trendelenberg test (checks abductors of the hip
gluteus medius): leg which the patient is standing
is the one being tested SOUND/NORMAL side is
going to SAG
o Tests gluteus medius muscles

o Problem in hip joint (severe OA)

o Shortening of neck of femur due to fracture
o SCFE (kids)
Inspection: both hips straight, swelling, deformity,
signs of inflammation, wasting of the muscles, flexion
deformity (side), back (spine is centered, wasting,
deformity)

Palpation: hip lying on the same level by palpating

with thumb the ASIS, greater trochanter (tenderness if
there is subtrochanteric bursitis), femoral pulse
midpoint between ASIS and pubic tubercle), palpate
lateral to femoral pulse to check for tenderness on
femoral head (osteoarthritis), muscles on the inner
side of the hip and front (adductor tendinitis)
Measure leg length: Apparent and true leg length
(measuring tape) discrepancy in true leg length
signifies pathology of hip joint; if in apparent leg length
means tilting of pelvis
Active and Passive Movements then Power:
o Hip flexion: raise leg to chest
o Extension: can ask patient to lower the leg
down or at the back ask patient to raise the
leg while knee is flexed; palpate the dimple
of venus or press hip (sacroiliac joint
tenderness sacroilitis)
o Abduction and Adduction (support hip)
o Internal and external rotation (flex and
support the knee)
Thomas Test: flexion deformity of the hip; keep hand
under spine and flex both hips and knees and ask the
patient to lower one leg; if not done properly, flexion
deformity will be disguised by lumbar lordosis
compensatory movement
Squeeze Test: flex knee at 90 degrees ask patient to
squeeze thighs in hand (+) in adductor
tendinitis/osteitis pubis
Tests for Sciatica
o Modified Straight Leg Test (L4-S1)
o Tibial Nerve Stretch Test (L4-S3)
o Femoral nerve Stretch Test (L2-4)

Diagnosis and Management

Most likely you have a condition called trochanteric
bursitis. The bony prominence of the thigh bone in the
upper part is the greater trochanter. There is a
protective shock absorber over the bone called
bursa. The muscles of the buttock is also attached to
this bone by the tendons. If there is inflammation of
the tendon or bursa, it is called trochanteric bursitis or
tendinitis.
You need to rest and reduce the activity for about a
few days. Put an ice pack on the painful side and I will
give you some painkillers to relieve the pain or
analgesic creams for massage. Please avoid sleeping
on the affected side. You can use sheep skin mat or a
small pillow to elevate the involved area
I will refer you to a physiotherapist for strengthening
exercises.
If severe pain: local anesthetic + corticosteroids;
surgery (rarely)
Investigations: XRay rule out osteoarthritis; USD:
can demonstrate the pathology
Overweight: lifestyle modification
Gait and Hip Examination (Osteoarthritis of the Hip)
Case: A 64-year-old man with a history of pain on his right hip
joint for the last 6 months comes to your GP clinic. The pain is
worse with activity. He tried panadol but didnt get relief from the
pain.

9
Task
a.

b.

Relevant hip examination and give commentary

(limping, unable to walk heels and toes and squat,
trendelenburg unable to do on the right side because
of the pain, leg length is normal, tenderness over the

right femoral head, flexion deformity on right side,

limited in range of movements on the right side,
thomas test positive)
Diagnosis and management

Case 2: You are working in a hospital followup outpatient clinic.

This 35-year-old man sustained a posterior dislocation of the
right hip in a MVA years ago. There were no associated injuries,
the dislocation was reduced and he had a period of bed rest
within traction followed by graduated ambulation and weight
bearing. He has been well since and has no problems apart
from occasional aching on prolonged exercise. He presents to
you for a checkup for insurance purposes.
Task:
a.
b.
c.

Perform PE of the hip with commentary

Advise patient of your opinion about the condition of
his hip
Advise patient of any further test which are required

Diagnosis and management

- It is a condition called osteoarthritis of the hip. It is a
condition resulting from wear and tear as a result of
excessive use of your joints over the years and also
due to old injuries in the affected joint. The cartilage
the covers and protect s the ends of the bones
gradually wears away causing the joint to become
rough and stiff. Most cases are mild and with
treatment, you can cope with it.
- Investigation: I will do an Xray of the hip joint to check
for bony spurs and narrowing of joint spaces.
- Management:
o Relative rest during acute pain, analgesia
and crutches
o Weight loss
o Heat: hot water bottle, warm shower, electric
blanket to reduce stiffness and pain
o Refer to physiotherapy for strengthening of
muscles and
o Occupational therapist for walking aids
o Surgery: hip joint is replaced by metal or
plastic and is successful in >90%
Adductor Tendinitis
Case: Your next patient in GP practice is a 20-year-old man
complaining of pain in the right groin.
Task
a.

Features
- Most common form of hip disorder
- Intrinsic disorder of articular cartilage or to secondary
OA
- Risk factors: previous trauma, DDH, septic arthritis,
acetabular dysplasia, SCFE, past inflammatory
arthritis
- M=F, usually bilateral; insidious; worse with activity,
relieved by rest and then nocturnal and after resting;
stiffness, limp and deformity; referred pain to groin,
medial aspect of thigh, buttock or knee
- PE: antalgic gait, gluteal and quadriceps wasting, first
hip movements lost: IR and extension, fixed flexion
deformity, hip held in flexion and ER (atfirst) IR,
extension, abduction, adduction, flexion, ER
- Treatment:
o Weight loss
o Relative rest
o Crutches for acute pain
o Analgesia
o Walking stick
o Physiotherapy
o Physical therapy (isometric exercise)
o Surgery: with severe pain or disability
unresponsive to conservative measures;
total hip replacement (old); femoral
osteotomy (younger patients); hip
resurfacing (<60 years; >90% achieve good
results; last 15-20 years)
Differential Diagnosis
- Osteoarthritis
- Avascular necrosis

b.
c.

History for 2 minutes (playing football when suddenly

twisted and heard popping sensation; upper groin pain
radiating to the thigh)
Perform Physical examination
Diagnosis and management

Case: David aged 27 years presents to your surgery in a busy

afternoon. He tells you he is having pain in his right leg and
finds it hard to play Footy nowadays. He is a professional player
and represents his team at state level. He had no injury or
trauma and denies any fall also. He had got some treatment by
team Physio and had used Panadol and Neurofen with no relief.
David is otherwise well and works as a salesman in a wellreputed firm
Task
a.
b.
c.

Further history (right leg 2-3 weeks especially in the

right upper medial thigh or groin area)
Physical examination (resisted adduction increases
pain, + Squeeze test,
Probable diagnosis and management advise

Differential Diagnosis
- Adductor tendinitis
- Iliopsoas problems
- Stress fracture of femoral neck
- Osteitis pubis (chronic pain) inflammation of
periosteal bone of symphysis pubis; pain on lower
tummy/pubic bone; point tenderness in symphisis
pubis;
- Hernia (Sport inguinal-femoral)
- Referred pain from lumbosacral spine
- Osteoarthritis of the hip joint
- Urologic disorders

10

Features
- Acute groin pain with history of twisting injury and
popping/snapping
- Pain inner thigh

History
-

Tenderness on palpation of the inner muscles of the

thigh and pain on adduction; squeeze test (+)
RICE
Prevention: stretching;

Task

Can you tell me more about what happened?

SORTSARA? Were you able to walk after that? Is it
for the first time? Did you have any numbness, tingling
or weakness? Swelling? Bruising? Did you take any
medications? Previous medications? General health?
History of joint problems?

Palpation
Temperature (of knee is 1 degree lesser than body),
Pulses (while seated popliteal, dorsalis pedis,
posterior tibial), sensation (pain and light touch),
reflexes,
Passive movement
Knees flexed: palate quadriceps, suprapatellar
pouches, patella, patellar tendon, shin of tibia, lateral
malleolus and fibula, head of the fibula, and joint line,
iliotibial band, knee hip joint, adductor muscle,
gastrocnemius, Achilles tendon
Patellar tap test and bulge test (mild effusion
effusion
Valgus and Varus stress test (+ if more than 10
degrees)
Anterior and posterior drawser (+ if more than 10
degrees)
Menisci
o Apleys Grinding test
o External rotation, valgus and flexion or
internal rotation, varus and extension
Patellar apprehension test (impending subluxation or
dislocation of patella)

Diagnosis and management

- Most likely you have a condition called Groin strain or
adductor tendinitis. It happens because of too much
stress on the muscles of your groin/thigh called
adductor muscles. If these muscles are tensed too
forcefully or suddenly they can tear causing pain. It is
a common condition during sports activity.
- Avoid activity until pain gets settled. Apply for 20-30
minutes for 3-4 hours until pain-free. You can also
compress the thigh with the help of elastic bandage or
tape.
- I will give painkillers and refer you to physiotherapy. If
still not relieved, I can refer you for corticosteroid
injection.
- Please come back if the pain is persistent. If we might
do ultrasound and Xray.
-

occasion, apprehensive when twisting to the right. Between

attacks of pain he can walk normally with only a minor feeling of
pain on the inner side of the knee. He is otherwise well. This is
the first time he has consulted a doctor about this problem.

Prevention: Do warm and stretching before doing

physical activity.

Examination of the Knee

Case (book pg229/280): A patient in your GP setting has past
history of twisting his right knee 6 months ago when foot got
caught on a broken pavement. He fell on the knee and it
became swollen and painful on the inner side. The swelling
caused a painful limp for several days and then subsided with
easing of symptoms.
Since then he has had intermittent attacks of pain on the inner
side of the knee with swelling, which settles within 24 hours, and
has had difficulty in straightening the leg fully. He is, on

a.
b.

Focused examination of the knee

Differential diagnostic plan

Inspection:
Landmarks
Patella
Tibial tuberosity
Popliteal fossa
Quadriceps femoris
Suprapatellar pouch
Medial and lateral pouches Peripatellar pouches
(obliterates when there is effusion)
Anserine bursa
Fractures, muscle wasting, scars (longitudinal
TKR, keyhole) , effusion, erythema, neurocutaneous
stigmata
Anterior plane: varus or valgus deformity
Lateral: hyperextension or flexion abnormalities
Posterior: swelling or baker cyst
Observe gait: normal gait, limping, fixed flexion
deformity
Squat and stand up (power and ROM full flexion
and extension)

Examination of ankle joint

Inspection: try to walk first; change in color of skin,
bruises, deformity
Palpation:
o Lateral: lateral malleolus, posterior tip of
lateral malleolus and 6 cm above, anterior
talofibular ligament, calcaneofibular
ligament, posterior talofibular ligament,
peroneal tendons, base of 5th metatarsal,
(sinus tarsi, distal syndesmotic ligament,
anterior calcaneal process not
necessary)
o Media: medial malleolus, medial joint line
with 6 cm above, 3 strips of ligament,

11

navicular, anterior joint line, Achilles tendon,

heel, pulse, CRT
ROM: plantar flexion, dorsiflexion, inversion, eversion,
neurovascular sensation, reflexes, power
Tests for ankle instability: anterior drawer, talar tilt, and
squeeze tests (signals high ankle/syndesmotic injury
patient needs MRI and referral for ORIF

Lower Leg Examination of a Patient with Diabetes Mellitus

(Diabetic Foot)
Case: Your next patient is a 55-year-old female with longstanding diabetes.
Task
a.

Perform physical examination of the lower limbs.

Ask patient to walk looking for gait and normal phases

of gait high-stepping gait (indicates loss of
proprioception or joint position sense)
Inspection:
o Needle marks and fat hypertrophy/atrophy,
wasting (especially quadriceps); charcot
joints (deformed knee joints)
o Skin: loss of hair, atrophy of the skin,
redness, cyanosis, signs of inflammation,
edema
o Feet for obvious deformities, boils, corns
and calluses, hammer toes (proximal
phalanx is flexed); mallet toe (DIP is flexed);
toe clawing (flexion of both DIP and PIP),
hallux valgus, bunions, tinea
o Nails (thickening, ingrown toe nail, change
of color, cyanosis), toes (cracks, ulcers)
Palpation:
o CRT, temperature, edema, pulses
o Neurologic examination: sensation, vibration
(toe medial/letaral malleolus knee
ASIS) proprioception, power (ankle and not
knee), tone, reflexes (ankle, knee may
be decreased or absent)
Urine dipstick, BSL, funduscopy

Diabetic Foot care

Keep diabetes under good control and do not smoke
Check feet daily (sores, infection or unusual signs)
Wash feet daily with lukewarm water, dry thoroughly
especially toes and soften dry skin especially around
the heels; applying methylated spirits between toes to
help stop dampness
Attend to toenails regularly (clip straight across with
clippers, do not cut them deep into corners or too
short across, file any rough edge)
Wear clean cotton or wool socks daily
Exercise your feet each day to help circulation
Check insides of shoes to make sure no nails are
pointing into the soles
Annual foot examination in doctors office
How to avoid injury
Wear good-fitting, comfortable leather shoes
Shoes should never be broken-in (should fit from the
start)
Shoes must not be too tight or too loose
Do not walk barefoot especially outdoors
Do not cut your own toenails if with poor eye sight
Avoid home treatments and corn pads that contain
acid
Be careful when walking around the garden and home
Do not use hot-water bottles or heating pads on your
feet
Do not test temperature of water with your feet
Take extra care when sitting in front of an open fire or
heater

Treating cuts and injuries

Clean would with mild antiseptic (liquid savlon or dilute
betadine)
Cover with clean gauze
See GP if does not heal within 2 days or there are
signs of infection
- Refer to podiatrist, dietitian, diabetic educator,
ophthalmologist and nephrologist