RCSI Clinical Examinations in Medicine 2018-19

CLINICAL EXAMINATIONS
Royal College of Surgeons in Ireland
Nicole Pierce
Senior Cycle 2 | 2018-19

Medicine
CONTENTS
No. Clinical Examinations Page
1 Cardiology 2
1 Clinical Examination of the Cardiovascular System 3
2 Respiratory Medicine 15
2 Clinical Examination of the Respiratory System 16
3 Gastroenterology 28
3 Clinical Examination of the Gastrointestinal System 29
4 Clinical Examination of a Stoma 40
5 Clinical Examination of a Hernia 43
4 Neurology 47
6 Neurological Examination of the Upper Limb 48
7 Neurological Examination of the Lower Limb 56
8 Clinical Examination of the Gait and Cerebellum 64
9 Clinical Examination of Speech 70
10 Clinical Examination of Higher Order Functioning 78
11 Clinical Examination of Parkinson Disease 82
12 Clinical Examination of the Cranial Nerves 87
5 Endocrinology 105
13 Clinical Examination of the Thyroid Gland 106
14 Clinical Examination for Acromegaly 114
15 Clinical Examination of the Breast 118
16 Clinical Examination of the Diabetic Patient 122
6 Musculoskeletal & Rheumatology 129
17 Surgical Examination of the Hands 130
18 Musculoskeletal Examination of the Hip 135
19 Musculoskeletal Examination of the Knee 140
20 Musculoskeletal Examination of the Shoulder 146
21 Musculoskeletal Examination of the Spine 151
22 Clinical Examination of Rheumatoid Arthritis 156
7 Vascular 163
23 Arterial Examination of the Lower Limbs 164
24 Venous Examination of the Lower Limbs 168
25 Vascular Examination of the Abdomen 172
8 Genitourinary 175
26 Clinical Examination of the Renal System and AV Fistula 176
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CHAPTER 1
CARDIOLOGY
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1. Clinical Examination of the Cardiovascular System
General Inspection
§ Alert/well/unwell
§ Breathing
o Rapid/laboured breathing
o Respiratory distress
§ Circulation
o Colour e.g. jaundice/cyanosis
o Abnormal pulsations
§ Devices
o O delivery
2
o ECG monitor
o IV fluids
o Catheter bag
o Pulse oximeter
o Medications e.g. GTN spray
§ Exposed
o Position at 45° supine, undressed to waist
o Obvious scars
Close Inspection of the Hands
Dorsum of the Hands:
§ Tar staining
§ Peripheral cyanosis
o Blue discolouration of the skin caused by reduced
blood supply to the tissues
o Only affects the skin, does not involve mucous
membranes
o May occur in severe central cyanosis
o Causes of peripheral cyanosis:
§ Peripheral vascular disease
§ Heart failure
§ Shock
§ Raynaud’s phenomenon
§ Severe central cyanosis
§ Oslers nodes
o Red, raised, tender nodules on the pulps of the fingers, thenar and hypothenar
eminences in infective endocarditis
§ Tendon xanthomata
o Lipid deposits in hyperlipidaemia
Nails:
§ Splinter haemorrhages
o Linear haemorrhages of nail caused by
infective endocarditis/vasculitis
§ Koilonychia (anaemia) – spooning of the nails
§ Pitting of the nails
§ Clubbing of the nails
o Loss of angle between the nail and nail bed
o Crouch down to closely inspect to the level of the hands
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o Cardiovascular causes of clubbing:

§ Cyanotic congenital heart disease
§ Infective endocarditis
§ Atrial myxoma
Grade Description
Grade 1 Fluctuation of the nail bed
Compress nail bed between fingers and gently rock
Grade 2 Loss of angle of nail bed
Get down to level of the fingers and examine
Grade 3 Increased curvature of the nail
Grade 4 ‘Drumstick’ appearance
Grade 5 Hypertrophic pulmonary osteoarthropathy (HPOA)
Palmar Surface of Hands:

§ Pallor of the palmar creases
o Can only be seen if hand is stretched
o Cardiovascular causes of anaemia (normochromic, normocytic anaemia):
§ Haemolytic anaemia (prosthetic heart valves)
§ Infective endocarditis (chronic inflammation)
§ Janeway lesions
o Non-tender erythematous maculo-
papular lesions containing bacteria on
palms or pulps of fingers in infective
endocarditis
o Bacteria stuck to the valves can be thrown
with infective emboli as blood passes
through the heart; if they travel to kidneys
they can cause haematuria
§ Endocarditis: Urine dipstick to find blood
“There are no peripheral stigmata of endocarditis”
§ Splinter haemorrhages
§ Janeway lesions
§ Osler nodes
Palpation
§ Temperature
o Determine that they are warm and well-perfused
§ Capillary refill time (<2 secs)
Close Inspection of the Wrist, Palpation of Pulse and Blood Pressure
Palpation of Pulse:
§ Palpate radial pulse using pulp of 2 and 3 fingers
nd rd
o Rate: 60-100 BPM

§ Bradycardia < 60/minute
§ Tachycardia > 100/minute
o Rhythm:
§ Regularly regular: Sinus rhythm
§ Regularly irregular: Heart block
§ Irregularly irregular: Atrial fibrillation
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o Volume
o Character
§ Radio-radial delay (Assess over 10 seconds)
o Palpate both radial pulses together
o Inequity in timing/volume due to aortic dissection/large arterial occlusion
o Causes of radio-radial delay:
§ Cervical rib
§ Aortic coarctation
§ Aortic dissection
§ Aortic embolism
§ Radio-femoral delay (Assess over 10 seconds)
o Palpate radial and femoral pulses together
o Delay in arrival of femoral pulse suggests coarctation of the aorta
§ Congenital heart disease
§ Aortic dissection
• Ascending aorta: type A
• Descending aorta: type B
§ Collapsing pulse
o Ask px if shoulder is in any pain
o Metacarpals of open palm against radial pulse
o Lift shoulder in air and support
o Pulse will thump against your fingers
o Aortic regurgitation
“John’s pulse is 64 beats per minute with regular pulsation of normal volume”
Causes of an Absent Radial Pulse:

1. Congenital absence (bilateral)
2. Previous arterial line/coronary angiography
3. Cervical rib
4. Coarctation of the aorta
5. Arterial embolism e.g. due to AF
Blood Pressure:
§ Systolic BP
o Peak pressure that occurs in the
artery following ventricular systole
o Pump to 20 above the anticipated
reading
§ Diastolic BP
o Level to which arterial blood
pressure falls during ventricular
diastole
§ Manual BP measurement with
Sphygmomanometer:
o Wrap the cuff around the upper arm
with the bladder over the brachial
artery, leaving the lower border of
the cuff about 2cm above the
antecubital fossa
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o Locate the radial artery, and with your other hand, squeeze the bulb to inflate
the cuff until the pulse is no longer felt
o Release the valve and note the pressure at which the pulse returns; this gives
you an estimate of what the systolic pressure is
o Close the valve and reinflate the cuff to 20-30mm Hg higher than your estimate
of systolic BP
o Place the diaphragm of your stethoscope over the brachial artery
o Remember that it can be uncomfortable for the patient to have the cuff inflated
to this pressure – do not forget this and do not waste time
o Release the valve a little so that the pressure drops very slowly. Meanwhile you
should listen intently for the Korotkoff sounds – faint thudding sounds
o Note the pressure at which you first hear the sounds – this represents systolic
pressure
o Note the pressure at which the sounds disappear – this represents diastolic
pressure. (Cuff pressure is now less than diastolic pressure and flow is
continuous throughout the cardiac cycle)
o Once the sounds have completely disappeared, open the valve fully to
completely deflate the cuff
Close Inspection of the Face
Face:
§ Malar flush (mitral stenosis)
§ Colour e.g. pallor/jaundice
Eyes:
§ Pallor of conjunctivae
§ Jaundice in conjunctivae
o Severe congestive cardiac failure leads to
hepatic congestion, causing intra-hepatic
jaundice
§ Xanthelasma
o Intracutaneous yellow cholesterol deposits
around the eyes may indicate
hyperlipidaemia
§ Corneal arcus
o Cholesterol deposits in the corneal stroma
result in a white/grey opaque ring surrounding the cornea
o Associated with hyperlipidaemia and with ageing
Mouth:
§ High-arched palate
o Feature of Marfans Syndrome
o Inspect roof of mouth
o Associated with aortic regurgitation
o Distinctive physical appearance – tall and thin, with an arm span that exceeds
height (arachnodactyly)
§ Dentition
o Poor dentition is a source of infective endocarditis
Mucous Membranes - Lips and Tongue:

§ Central cyanosis
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o Caused by reduced arterial oxygenation as defined as >5g/dL deoxygenated

haemoglobin in the blood
o Examine beneath the tongue for blueish discolouration
o Affects the mucous membranes and is improved with oxygen therapy
o Causes of central cyanosis:
§ Hypoxic lung disease
§ R →L cardiac shunt
• Eisenmengers syndrome
• Cyanotic congenital heart disease
§ Methaemoglobinaemia
• Drugs
• Toxins
Close Inspection of the Neck
Assessment of Carotid Arteries:
§ Provides information about aorta and
left ventricular function
§ Inspection of carotids:
o Medial to the
sternocleidomastoid muscles
§ Palpable pulsation
(you cannot feel a
venous pulsation)
§ Ask patient to turn
head posteriorly and
to the left
o Look for exaggerated
pulsation (Corrigan’s sign) seen in aortic regurgitation
§ Palpation of carotids:
o Assessment of pulse character
o Only palpate one side at a time
§ Evaluate the pulse wave form [collapsing pulse of aortic regurgitation]
§ Findings: “This patient has strong carotid pulse”
Jugular Venous Pressure (JVP):

§ Use internal jugular vein to examine the function of the right side of the heart
(internal jugular vein has no valves and gives good indication of the function of the
right side of heart)
§ Internal jugular vein is medial to sternomastoid muscle
§ External jugular vein is lateral to sternomastoid muscle
§ Measurement of the JVP:
o Measured as vertical distance between sternal angle and top of the venous
column
o Look along course of the internal jugular vein
o Manubriosternal angle:
§ 1 rib down from sternal notch
§ Take the highest point of the pulsation
§ Distance from manubriosternal angle to the height of the JVP
§ Anything above 2cm is abnormal
• Causes: Tricuspid valve stenosis
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• Fluid overload (if someone has forgotten to take IV out)

• If patient is laid down flat, there would be a venous pulsation
in his neck
§ The column of blood in the internal jugular vein extends into the right atrium
§ It enables us to observe pressure changes in the right atrium
“This patient does not appear to have an elevated JVP”
§ Gentle pressure at the base of the neck may abolish visible pulsations and may make
a vein visible by causing distension above the occlusion
Features of Elevated JVP:

§ Palpation: Non-palpable
§ Occludable, fills from above
§ Location: Between heads of SCM, lateral to
carotid artery
§ Inspiration: Decreases with inspiration
§ Contour: Biphasic waveform
§ Erection/Position: Decreases on sitting erect,
increase with upward pressure of the liver
(hepatojugular reflux)
Hepatojugular Reflux:
§ Pressure on the liver or abdominal area (right upper quadrant)
§ Put a flat hand over the liver
§ Transient rise in JVP
§ Abdominal compression increases venous return and pressure and facilitates analysis
of the JVP
§ Apply firm sustained pressure over upper abdomen
§ It is a simple way of confirming the venous nature of a pulsation in the neck
Causes of Elevated JVP:

1. Right ventricular failure
2. Renal failure - fluid overload
3. SVC obstruction
4. Tricuspid regurgitation/stenosis
5. Pericardial effusion
6. Constrictive pericarditis
7. Cardiac tamponade
Close Inspection of the Praecordium
§ Symmetry of the chest
§ Scars
o Sternotomy [a cut down the middle of the sternum - CABG and valve
surgery]
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o Thoracotomy [mitral valvotomy - a stenosed mitral valve is opened through

an incision made in the left atrium]
o Groin (catheterisation)
§ Chest wall deformities
§ Skeletal abnormalities
o Marfan’s Syndrome may cause pectus excavatum/kyphoscoliosis
o Severe deformity may cause distortion of the position of the heart and great
vessels and also interfere with pulmonary function]
§ Pacemaker in situ
Palpation of the Chest
Apex Beat:
§ The most lateral, inferior point at which the palpating fingers are raised with each
systole
§ Begin in the axilla with flat of the hand underneath the nipple because you may miss
an enlarged heart
§ Move medially until apex beat is located
§ Normal position is in the 5 ICS MCL
th
§ To locate position of apex beat count down the number of interspaces

§ Reference point is the 2 intercostal space lies just below the manubriosternal angle
nd
o Apex beat may be displaced laterally or inferiorly or both

o This usually indicates enlargement but may be due to chest wall deformity
§ Rarely in dextrocardia where there is inversion of the heart and the great vessels the
apex beat will be palpable to the right of the sternum
§ Apex beat is best located with the patient in the left lateral position, in order to
position the apex closer to the chest wall
§ Assessment of character of apex beat:
o Heaving (LVH)
o Thrusting
§ Mitral regurgitation
§ Aortic regurgitation
§ LVF
o Tapping (mitral stenosis)
Causes of Impalpable Apex Beat:

1. Obesity
2. Emphysema (hyperexpansion)
3. Pericardial effusion
4. Shock
5. Dextrocardia
Causes of Displaced Apex Beat:

1. Left ventricular dilatation
2. Right ventricular dilatation
3. Cardiomegaly
4. Chest wall deformities
5. Mediastinal mass
Parasternal Heave:
§ Parasternal heave may be palpable when the heel of the hand is rested just to the left
of the sternum, place the hand onto the chest with fingers spread
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§ This is present in right ventricular enlargement/hypertrophy

o Fingers in the intercostal spaces down the LSE
o Sign of right ventricular hypertrophy or enlargement
o Fingers will be moving up and down if positive
Thrills:
§ Palpable murmurs
o Murmur is due to turbulent blood flow
§ Praecordium should be palpated for thrills with the flat of the hand
§ Palpate over the apex, left sternum and base of the heart (in a Z)
§ Apical thrills are best elicited with the patient in the left lateral position, in order to
position the apex closer to the chest wall
Auscultation of the Chest
1. Mitral (apex beat): 5 left ICS MCL

th
2. Tricuspid (LLSB): 4 left ICS, left

th
sternal border
3. Pulmonary: 2 ICS, left sternal edge
nd
4. Aortic: 2 ICS, right sternal edge

nd
S1: Mitral and tricuspid valve

S2: Aortic and pulmonary valve
Between S1 – S2: Systole

Between S2 – S1: Diastole
Method of Auscultation:
§ Bell
o Designed for listening to low-pitched sounds (don’t press too hard)
o e.g. mitral stenosis best heard with the patient lying on the left hand side using
the bell of the stethoscope
o Diastolic murmur
§ Diaphragm
o Auscultation of high-pitched sounds
o e.g. mitral incompetence
§ Listen over all 4 areas with bell and the diaphragm; palpation of carotid pulsation
will indicate the timing of systole and allow heart sounds to be identified
o Place diaphragm of stethoscope (for high-pitched sounds) on apex beat
o Move up to 4 areas with diaphragm
o Change to bell (for low-pitched sounds) at aortic area
o Move back down to apex beat
Heart Sounds:
§ S1: Mitral and tricuspid valve closure
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o Beginning of systole
§ S2: Aortic and pulmonary valve closure
o A component: Closure of the aortic valve
o P component: Closure of the pulmonary valve
o Beginning of diastole
o Lower pitch
Added Sounds:
§ S3:
o Low-pitch mid-diastolic sound
o Pathological S3 ‘gallop rhythm’ is due to reduced ventricular compliance:
Filling sound is produced even when diastolic filling is not rapid e.g. heart
failure
o Normal in some young children
§ S4:
o Always pathological – caused by severe heart failure
o Mechanical heart valve (click)
“On auscultation of this patients heart, heart sounds 1 & 2 were heard and there were no
added cardiac sounds”
Grade Description of Murmur

1/6 Very soft
2/6 Soft
3/6 Moderate, no palpable thrill
4/6 Loud, thrill palpable
5/6 Very loud, thrill easily palpable
6/6 Very, very loud, audible without stethoscope
Dynamic Manoeuvres:
§ Lesions on the left side of the heart are best elicited on
listening in full expiration
o Aortic stenosis/regurgitation
o Mitral stenosis/regurgitation
§ Lesions on the right side of the heart are best elicited on
full inspiration
o Pulmonary stenosis/regurgitation
o Tricuspid stenosis/regurgitation
Murmur Manoeuvre
Mitral Regurgitation Systolic murmur
Listen with diaphragm at axilla
Mitral Stenosis Diastolic murmur
Left lateral position, listen with bell at mitral area
Aortic Regurgitation Diastolic murmur
Sit px forward in full expiration, listen with diaphragm to LLSB
Aortic Stenosis Systolic murmur
Listen to carotids with diaphragm/bell for carotid bruits
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Prosthetic Heart Valves

§ Aortic valve: Congruent with 2 HS, synchronous with systole
nd
§ Mitral valve: Congruent with 1 HS, asynchronous with systole

st
Differential Diagnosis for Cardiac Murmurs

Pansystolic Murmur: Audible Throughout Systole
1. Mitral regurgitation
2. Tricuspid regurgitation
3. VSD
Ejection Systolic Murmur: Audible best at mid-systole
1. Aortic stenosis
2. Pulmonary stenosis
3. Hypertrophic obstructive cardiomyopathy (HOCM)
Early Diastolic Murmur: Loudest at beginning of systole
1. Aortic regurgitation
2. Pulmonary regurgitation
Mid-Diastolic Murmur: Begins later in diastole
1. Mitral stenosis
2. Tricuspid stenosis
Continuous Murmur: During both diastole and systole
1. AV fistula
2. PDA (‘machinery like’)
To Complete Examination
Examination of the Posterior Chest Wall
§ Lung bases
o Auscultate for crackles due to congestive cardiac failure/pleural effusion
o Percussion for pulmonary oedema (CCF/pleural effusion)
§ Sacral oedema
o Due to CCF
Examination of The Abdomen
§ Hepatomegaly
o The liver may be enlarged and/or tender due to congested hepatic veins
caused by right-heart failure
o A pulsatile liver is a feature of tricuspid regurgitation
§ Splenomegaly
o Splenomegaly may be present in infective endocarditis
Examination of The Legs
§ Scars e.g. harvesting of veins for CABG
§ Pitting oedema
o Palpate distal shaft of tibia, compress the area for
at least 15 seconds with the thumb
o Skin is indented and only slowly refills
o *Area often tender be gentle* Note:
§ Upper level of oedema
§ Abdominal wall/scrotal involvement
§ Pedal pulses – should be examined to assess for
presence of co-existing peripheral vascular disease
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CHAPTER 2
RESPIRATORY MEDICINE
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2. Clinical Examination of the Respiratory System
General Inspection
§ Alert/well/unwell
§ BMI e.g. cachexia
§ Breathing
o Position: Any tripod sign? Arms forward, sitting upright
o Use of accessory muscles (look closely)
§ SCM
§ Traps
o Signs of respiratory distress
§ Intercostal
§ Respiratory rate: Measure for 15 seconds and x 4
• Tachypnoea: Rapid respiratory rate
• Normal RR: 12-20/min
o Added sounds
• Cough:
o Productive → exacerbation of COPD
o Dry → bronchospasm e.g. asthma
• Wheeze e.g. severe asthma
• Stridor: Rasping noise loudest on inspiration caused by
obstruction of larynx/trachea/large airways e.g. foreign
body/tumour
• Hoarseness: Laryngitis/laryngeal/lung CA
§ Colour
o Cyanosis
o Polycythaemia
§ Due to chronic hypoxia in COPD
§ Devices
o Medications
o Oxygen masks/nasal prongs
o Inhalers
o Sputum pot
o Nebulisers
o Chest drains
§ Exposure
o Position at 45° supine, undressed to waist
Dorsum of the Hands
§ Tar staining
§ Peripheral cyanosis
Nails
§ Clubbing
o The normal angle between the nail and the
cuticle immediately proximal to the nail is
around 140-160°
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§ Respiratory causes of clubbing:

o Asbestosis
o Cystic fibrosis
o Pulmonary fibrosis
o Mesothelioma
o Bronchial carcinoma
o Bronchiectasis
o Empyema
o Lung abscess
Grade Description
Grade 1 Fluctuation of the nail bed
Compress nail bed between fingers and gently rock
Grade 2 Loss of angle of nail bed
Grade 3 Increased curvature of the nail
Grade 4 ‘Drumstick’ appearance
Grade 5 Hypertrophic pulmonary osteoarthropathy (HPOA)
Palmar Surface
§ Pallor of palmar creases
§ Wasting of the thenar and hypothenar eminences
o Due to Pancoast tumour
• Peripheral cyanosis (cold blue hands)
Tremor
§ Ask patient to hold their hands out in front of them
§ Note any fine tremor which may be caused be inhaled bronchodilators
§ Most common cause is salbutamol (e.g. asthma/COPD), can also be caused by CO 2
retention
Close Inspection of the Wrist
Asterixis
§ Ask patient to dorsiflex the wrist with arms outstretched and fingers spread
§ Gross flapping tremor : Sign of CO retention caused by chronic airflow limitation
2
e.g. COPD
§ Ddx:
o Uraemic asterixis
o Hepatic encephalopathy
Radial Pulse
§ Assess rate and rhythm at radial artery
o Tachycardia: May be caused by respiratory distress/hypoxia
o Volume: Increased pulse volume may be a sign of CO retention
2
o Pulsus paradoxus: Decrease in pulse pressure by >20mmHg on inspiration

which may occur in severe asthma
o Bounding pulse: Classic pulse with CO retention
2
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Respiratory Rate
§ Assess over 30 secs and multiply x 2
§ Normal: 12-20/min at rest in adults
Blood Pressure
§ Offer manual BP
Signs of CO Retention:
2
1. Tremor
2. Bounding pulse
3. Asterixis
4. Chemosis (conjunctival oedema classically caused by CO retention, also found in
2
thyrotoxicosis and SVC obstruction)

5. Altered mental status
Face:
§ Cushingoid facies
Eyes:
§ Conjunctival pallor (sign of anaemia)
§ Chemosis (CO retention)
2
§ Horner’s syndrome:
o Ptosis
o Miosis (fixed constricted pupil)
o Anhydrosis
o Enophthalmos
Mouth and Tongue:
§ Central cyanosis (stick out the tongue and look underneath for central cyanosis)
o Bluish discolouration of skin and mucous membranes due to the presence of
>5g/dL of deoxygenated haemoglobin in the superficial blood vessels
o Hb molecule changes colour from blue to red when oxygen is added to it in
the lungs
o If the level of deoxygenated blood is >5g/100ml blood, there will be an
abnormal blueish tinge to the tissues
o Cyanosis becomes noticeable when O sat falls below 90% in a person with
2
normal haemoglobin level

o Patients who are centrally cyanosed will usually also be peripherally
cyanosed
o Blue lips is not central cyanosis
o When peripheral vasoconstriction occurs, the blood supply to the affected
part of the body is reduced and the tissues extract more oxygen than normal
e.g. the lips/hands in cold weather may appear blue
o Patients with peripheral cyanosis will not necessarily be centrally cyanosed
unless they have an underlying cardiac/respiratory disorder
o Low cardiac output or impaired venous return may result in excess extraction
of oxygen from peripheral blood leading to peripheral cyanosis
§ Dental caries (abscess in the lung may have dental caries)
§ Candida (secondary to steroids)
o Particularly if in hospital for a long time
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Tracheal Deviation*
§ Is the trachea central or is it deviated from the
midline?
§ Explain to the patient that you are going to
press gently on their neck and that it may be a little
uncomfortable
§ Use the forefinger of the right hand to palpate
for the position of the trachea above and
backwards from the suprasternal notch
§ If displacement of trachea is present its edge
rather than its middle will be palpated and a larger
space will be present on one side than the other
§ Displaced towards side of the lung lesion

o Upper lobe collapse
o Upper lobe fibrosis
o Pneumonectomy
§ Displaced away from side of lung lesion (uncommon)
o Massive pleural effusion
o Tension pneumothorax
* Consolidation does not cause tracheal deviation
Tracheal Tug
§ Feel or see the trachea move inferiorly with each inspiration- sign of overexpansion
of the chest because of airflow obstruction
§ Can also be seen in babies with respiratory distress, commonly secondary to
bronchiolitis
Lymph Nodes
§ Ask the patent to sit forward, stand behind the
patient and explain that you are going to examine the
patient’s neck
§ When examining for lymph node, note:
o Site: exactly where in the body this lump is.
This can be described accurately using
various landmarks and surface anatomy that
you will be learning
o Shape
o Size: this should be measured and described
accurately e.g. 1cm, not 'the size of a pea'. Large nodes are usually abnormal
(greater than 1 cm)
o Temperature: Does the lump feel warm or cold compared to the surrounding
area
o Tenderness: Does touching the lump cause the patient to feel pain or
discomfort; usually implies acute inflammation or infection
o Tethering: Is the lump attached to other structures e.g. the skin above it or
the bone, muscle or other structure below. Nodes that are fixed to underlying
structures are more likely to be due to carcinoma
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o Colour: Variation in the colour of the lump or the overlying skin compared
to normal or the surrounding area
o Consistency: Hard nodes suggest carcinoma, soft may be normal and rubbery
nodes may be due to lymphoma
§ Hard: Solid like a stone
§ Firm: Not solid but has a little 'give' e.g. like a tennis ball
§ Soft: Squashy
o Contours (edges and irregularity): Is the lump smooth or does it have sharp
edges or craggy feel to it
§ Sit the patient up and examine the neck from behind:
o Carefully palpate for the following lymph nodes in turn: the SUBMENTAL
node, which lies directly under, the chin, then the SUBMANDIBULAR
nodes which are below the angle of the jaw
o Posterior to the angle of the jaw feel for the PAROTID node then palpate in
front of the tragus for the PREAURICULAR node
o Now palpate behind the ear for the POSTAURICULAR node, then to the
posterior aspect of the head for the OCCIPITAL node
o Now ask the patient to relax their shoulders and palpate down the anterior
border of the sternocleidomastoid muscle for the ANTERIOR CERVICAL
CHAIN of nodes including the TONSILLAR (JUGULODIGASTRIC) node
o At the inferior end ask the patient to slightly shrug their shoulders and feel
for the SUPRACLAVICULAR nodes
o Now palpate for the POSTERIOR CERVICAL CHAIN of nodes at the
posterior border of the sternocleidomastoid muscle and the posterior triangle
of the neck
Close Inspection of the Chest
§ Scars e.g. pneumonectomy, lobectomy, radiotherapy marks (skin may appear
erythematous/thickened, e.g. tx of lung CA, breast CA, lymphoma), midline
thoracotomy scars, previous chest drains, trauma
§ Hoovers sign:
o Intercostal indrawing due to hyperinflation
§ Symmetry of chest wall movement
o Ask the patient to take a deep breath in
and out
o Is the chest moving with respiration?
o Is the movement equal and symmetrical
on both sides? A large effusion, pneumothorax, area of collapse etc in one
lung can cause asymmetrical movement
o Pectus Excavatum (funnel chest) is a depression
of lower end of sternum (in severe cases lung
capacity may be restricted)
o Pectus Carinatum (pigeon chest) is a
prominence (outward bowing) of sternum and
costal cartilages. Can occur with chronic
childhood respiratory illness and rickets
o Barrel-shaped chest antero-posterior diameter is
increased compared with the lateral diameter.
This indicates chronic hyperinflation e.g. severe asthma and emphysema
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§ Deformities
o Kyphoscoliosis: Forward curvature
of the spine
§ Severe kyphoscoliosis may
reduce lung capacity and
increase the WOB
o Scoliosis: Lateral curvature of the
spine
§ Devices e.g. Portacath in situ
Palpation of the Chest
Chest Expansion
§ Measure chest expansion to determine if expansion is equal on both sides
§ Causes of asymmetrical (one-sided) reduced chest expansion:
o Consolidation
o Collapse
o Ipsilateral pleural effusion
o Ipsilateral pneumothorax
§ Causes of bilateral reduced chest expansion:
o COPD (as chest is hyperinflated)
§ Method of assessment:
o Place hands on lower posterior chest wall with fingers extending around the
sides of the chest
o The thumbs are lifted slightly off the
chest and should almost meet in the midline
o On inspiration the thumbs should move
symmetrically apart at least 5cms
o Ask the patient: “Take a breath in, and
let it all the way out”. When they are in full
expiration, place your hands over the lower
ribs and stretch your thumbs out until they
meet in the midline. “Take a deep breath in
please” The distance your thumbs move apart
is measured in cm
o Palpation of the posterior chest wall
measures lower lobe expansion
Tactile Fremitus
§ Ask px to cross their arms at front (to move scapula out of way)
§ Place hand on chest and ask px to say ‘99’ as you palpate down chest wall, comparing
sides
§ Do one hand at a time and compare symmetrical sides (like with like)
§ Increase in vibration may be felt on one side – this indicates lung consolidation (lobar
pneumonia)
§ Markedly reduced over pleural effusion – only effective sign for this pathology
Percussion of the Chest
Method of Percussion:
§ Approach the posterior chest from behind
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Medicine
§ Ask the patient to cross the arms in front of chest (moves scapula out of way)
§ Technique:
o Begin in supraclavicular fossae
o Percuss the clavicles directly
o Percuss down the chest
posteriorly
o The left middle finger is pressed
firmly against the chest
o With the pad of the right middle
finger strike firmly the middle
phalanx of the middle finger of
the left hand
o The percussing finger must be
held slightly flexed and a loose
swinging movement should come
from the wrist
o Remove the finger quickly so that the note generated is not dampened
o Percussion of symmetrical areas of the anterior, posterior and axillary
regions is necessary
o Compare right and left sides at each level
o Fan out at the bases
o Percuss down as far as T10 posteriorly
o Remember to include axilla
§ Abnormalities in percussion:
o Normal lung is resonant to percussion
o Hyperresonant: Air e.g. pneumothorax
o Dull: Solid e.g. consolidation/tumour
o Stony dull: Fluid e.g. pleural effusion
Auscultation of the Chest
Method of Auscultation:
§ Move scapula out of the way (cross arms anteriorly)
§ Auscultate down the posterior chest
§ Compare right and left sides at each level
§ Fan out at the bases
§ T10 posteriorly
§ Include axilla
Auscultate for:
§ Quality of breath sounds
o Vesicular breath sounds:
§ Produced in the airways
§ Normal breath sounds are louder and
longer on inspiration and there is no
gap between inspiratory and expiratory sounds
§ They are due to the transmission of air turbulence in the large airways
filtered through the normal lungs to the chest wall
o Bronchial breath sounds: (e.g. as the sound over a trachea)
§ Due to turbulence in the large airways without being filtered by the
alveoli
§ They have a hollow and blowing quality
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§ Often a gap is present between inspiration and expiration

§ Heard over areas of:
• Consolidation [pneumonia]
• Localised pulmonary fibrosis
• Pleural effusion
• Lung collapse
§ Intensity of breath sounds
o Causes of reduced intensity:
§ COPD [especially emphysema]
§ Pneumothorax
§ Pulmonary fibrosis
Surface Anatomy
Right upper
lobe Left upper lobe
Right middle
lobe
Right lower Left lower lobe

lobe
§ Added sounds e.g. wheeze/crackles

o Wheeze: Caused by the oscillation of opposing airway walls and imply
significant airway narrowing:
§ May be heard on inspiration or expiration or both
§ They tend to be louder on expiration
§ An inspiratory wheeze implies severe airway narrowing
§ Usually the result of acute [asthma] or chronic [COAD] airflow
obstruction
o Crackles/crepitations: Interrupted non-musical sounds
§ Ask the patient to cough – do they shift on cough?
§ Ask the patient to breathe in and out – are they inspiratory/expiratory?
§ Are they coarse or fine crackles?
§ Probably the result of small peripheral airways collapsing on
inspiration and expiration
§ Early inspiratory crackle suggest disease of the small airways
characteristic of chronic airflow limitation
§ Late or pan inspiratory crackles are suggestive of alveolar disease.
They may be fining medium or coarse
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Medicine
o Fine crackles: Similar to hair rubbed between the fingers e.g. pulmonary
fibrosis
o Medium crackles e.g. LVF
o Coarse crackles: Characteristic of pools of retained secretions and have an
unpleasant gurgling quality
§ Tend to change with coughing e.g. pneumonia or bronchiectasis
o Pleural rub: Due to thickened, roughened pleural surfaces rubbing together as
the lungs expand and contract e.g. pulmonary infarction/pneumonia
Vocal Resonance
§ While auscultating over the chest wall, ask the px to repeat “ninety nine”
§ Findings:
o Increased vocal resonance: Consolidation (bronchial breathing is also likely
present)
o Muffled: Normal
Cardiovascular Examination
§ Signs of right-sided heart failure
o Elevated JVP
o Pitting oedema
o Tricuspid regurgitation
o Hepatomegaly
o RV heave
§ Position of apex beat
o Displacement towards the side of lesion can be caused by collapse of lower
lobes
o Displacement away from the side of lesion can be caused by pleural
effusion/tension pneumothorax
o Impalpable in case of hyperinflation e.g. COPD
§ Auscultate for heart sounds
o P2: Pulmonary component of the S2
o Loud P2:
§ Pulmonary hypertension which may be secondary to:
• Chronic airflow limitation
• Pulmonary fibrosis
• Pulmonary VTE
• Obesity
• Sleep apnoea
• Severe kyphoscoliosis
Examination of the Abdomen
§ Hepatomegaly
o Ptosis (due to CO2 retention e.g. COPD)
o Hepatomegaly (due to metastatic deposits secondary to lung cancer)
Pemberton’s Sign
§ Lift both arms over the head and wait for 1 minute
§ Observe for signs of SVC obstruction:
o Facial plethora
o Inspiratory stridor
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o Cyanosis
o Non-pulsatile elevation of JVP
o Pre-syncopal symptoms
Examination of Lower Limbs

§ Pedal oedema e.g. Cor pulmonale
§ Unilateral calf swelling + tension e.g. DVT
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CHAPTER 3
GASTROENTEROLOGY
28
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3. Clinical Examination of the Gastrointestinal System
General Inspection
§ Level of consciousness e.g. hepatic encephalopathy
§ Distress: Dyspnoea/obvious pain
§ Colour: Jaundice/pallor/slate grey pigmentation (haemochromatosis in liver
disease)/bruising (consistent with IV cannulation etc.)
§ Nutritional status: Cachexia/high BMI/obvious distension
§ Devices: e.g. NG tube/IV fluids/TPN/emesis bowl
§ Exposure: From nipple to knee, for purpose of exam nipple to pubic symphysis is
fine
§ Hernia exam: Hands behind the head and ask to cough (for Prof Walsh only)
§ Position: Sitting at 45° supine, must lie them flat for abdominal inspection
Nails
§ Clubbing
o An increase in the soft tissue of the distal part of the fingers or toes
o GI causes of clubbing:
§ Coeliac disease
§ Inflammatory bowel disease
§ Cirrhosis
§ Primary biliary cholangitis
§ Chronic active hepatitis
§ Leuconychia
o Opacification of the nail bed
o Caused by:
§ Chronic liver disease
§ Hypoalbuminaemia
§ Koilonychia
o Iron deficiency anaemia
Palms
§ Palmar erythema
o Reddening of the palms affecting the
thenar and hypothenar eminences
o Caused by chronic liver disease
§ Pallor of palmar creases
o Caused by anaemia
§ Dupuytren’s contracture
o Thickening of the palmar fascia causing
a flexion contracture of one or more
fingers
o Associated with alcohol dependency,
but may also be idiopathic (majority of
cases)
29
Medicine
Close Inspection of the Wrist and Arms

Wrist
§ Pulse
§ Hepatic flap (asterixis)
o Ask the patient to stretch out the arms in front, separate the fingers and
extend the wrists x 15 seconds
o Observe for jerking, irregular movement at the wrists
o Sign of hepatic encephalopathy
o Causes:
§ Hepatic encephalopathy
§ CO retention
2
Arms
§ Ecchymoses (large bruises)
o Clotting abnormalities secondary to chronic liver disease
§ Petechiae (pinhead sized bruises)
o Clotting abnormalities secondary to chronic liver disease
§ Spider naevi
o Central arterioles from which small vessels radiate, akin to spiders legs
o Caused by chronic liver disease (>3 is abnormal)
o Found on arms, neck and chest
§ Muscle wasting
o Malnutrition of chronic alcoholism
§ Pruritic scratch marks
o Pruritus of chronic liver disease
§ Track marks/puncture wounds
o IVDU drug abuse
Ecchymosis Petechiae
Eyes
§ Conjunctival pallor
o Anaemia
§ Scleral icterus
o Jaundice
§ Xanthelasma
o Fatty deposits due to
hypercholesterolaemia
30
Medicine
Mouth & Tongue

§ Dentition
§ Aphthous ulcers
o Inflammatory bowel disease
§ Dry mouth
o Dehydration
§ Fetor hepaticus
o Sweet-smelling
§ Candidiasis
o White plaques which cannot be removed
§ Glossitis
o Caused by deficiencies in iron, folate and vitamin B group
o Smooth appearance to surface of tongue
§ Angular stomatitis
o Caused by iron deficiency anaemia
§ Chelitis
o Caused by iron deficiency anaemia
Oral Candida Glossitis

Lymph Nodes
§ Evaluate for Virchow’s node (palpable
in left supraclavicular fossa)
§ Nodal groups:
o Submental
o Submandibular
o Pre-auricular
o Posterior auricular
o Posterior cervical
o Occipital
o Anterior cervical
o Supraclavicular
Jugular Venous Pressure

§ May be caused by portal hypertension
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Medicine
Close Inspection of the Abdomen*

*Lie the patient flat with one pillow under their head for comfort. The examiner should be
at the same level as the abdomen.
Scars
§ Inspect the anterior abdomen for scars e.g. McBurneys, suprapubic scar
§ Inspect the posterior abdomen for scars e.g. nephrostomy
Skin
§ Colour e.g. jaundice
§ Scratch marks (pruritus due to chronic liver disease)
Striae
§ Caused by stretching of
abdominal wall
§ Associated with excessive
weight gain/loss or steroid use
Stomata
§ Ileostomy
§ Colostomy
§ Urostomy
Distension
§ Generalised abdominal
distension may be caused by:
o Fat (obesity)
o Flatus (gaseous distension due to bowel obstruction)
o Fluid (ascites)
o Faeces (constipation/bowel obstruction)
o Foetus (pregnancy)
o Filthy big tumour (abdominal mass)
§ Gynaecomastia
o Presence of breast tissue in males
o Associated with chronic liver disease
32
Medicine
Masses/Herniae
§ Hernia: Protrusion of an intra-abdominal structure through the boundaries which
normally confine it
§ Ask the patient to bring their chin to their chest and cough
Palpation of the Abdomen*
*It is important to explain to the patient what you are about to do and ask them if any
particular area is tender and then examine this area last. Encourage the patient to relax.
Superficial Palpation
§ Begin with superficial (light) palpation in all 9 areas of
the abdomen
§ Watch patient’s face closing for tenderness, guarding
(voluntary/involuntary resistance to palpation due to
contraction of abdominal muscles) or superficial masses
in each area
§ Palpation is performed with the palmar surface of the
fingers acting together
§ To palpate the edges of organs or masses the lateral surface of the forefinger is used
Deep Palpation
§ Detects masses, guarding and rigidity (constant involuntary contraction of
abdominal muscles, which is always associated with tenderness and indicates
peritoneal irritation)
§ Rebound tenderness is said to be present when after compressing the abdominal
wall slowly a sharp pain occurs on rapidly releasing the compression; occurs with
peritonitis
§ Any mass found must be described and
defined:
o Size
o Shape
o Surface (regular/irregular)
o Consistency (hard/soft)
o Tenderness
o Mobility
o Movement with respiration
o Edge (regular/irregular)
o Pulsatile
Palpation of the Liver

§ Begin in the RIF with the examining hand aligned parallel to the right costal margin
§ Ask the patient to breathe in and out slowly through the mouth
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Medicine
§ During inspiration the hand is held still and the lateral margin of the forefinger waits
for the liver edge to strike it (the liver should move downwards with inspiration as it
is pushed down by the diaphragm)
§ On expiration the hand is advanced by 1-2cms closer to the right costal margin
§ If the liver edge is identified the surface of the liver should be felt: it may be hard or
soft, tender or non-tender, regular or irregular and pulsatile or non-pulsatile
§ The normal liver edge may just be palpable below the coastal margin on deep
palpation especially in thin people
Palpation of the Spleen

§ The spleen enlarges inferiorly and medially
§ Begin with the examining hand in the right iliac fossa and with the same technique
used to examine for the liver slowly move the hand towards the left costal margin
§ If the spleen is not palpable a two-handed technique is recommended
§ The left hand is placed posterolaterally over the left lower ribs and the right hand is
placed on the abdomen parallel to the left costal margin
§ As the right hand is advanced towards the left coastal margin the left hand
compresses firmly over the rib cage
§ This enables a slightly enlarged soft spleen to be felt as it moves down towards the
RIF
§ If the spleen is still not palpable the patient is rolled onto the right side towards the
examiner and palpation is repeated
§ Begin palpation close to the left costal margin
§ Splenomegaly becomes just detectable if the spleen is one-and-a-half to two times
enlarged
Palpation of the Kidneys: Ballotment

§ The bimanual balloting method is used
§ To palpate the right kidney the examiners left hand slides underneath the back to rest
with the heel of the hand under the right loin
§ The fingers remain free to flex at the metacarpophalangeal joints in the area of the
renal angle, whilst the examiners right hand is placed over the RUQ
§ Press over the renal angle by flexing the fingers of the posterior hand
§ The kidney can be felt to float upward and strike the anterior hand
§ The left kidney is examined in the same way using the right hand on the abdomen
and the left hand underneath in the area of the left renal angle
§ It is unusual to feel a normal kidney, although the lower pole of the right kidney may
be palpable in thin, normal people. Both kidneys move downwards with inspiration
Abdominal Aorta: Assessment for AAA

§ Arterial pulsation from the abdominal aorta may be felt in the epigastric area of thin
normal people
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Medicine
§ Check for an abdominal aortic

aneurysm (AAA) at the midpoint
between the xiphisternum and the
umbilicus using the two index
fingers aligned parallel to the aorta
§ Start with the two index fingers
approximately 10cm apart and move
them medially
§ A normal pulsatile mass should be
present but it should not be expansile
§ An abdominal aortic aneurysm
(AAA) is defined as an enlargement
of the aorta of at least 1.5 times its
normal diameter or greater than 3 cm
diameter in total
Bladder
§ An empty bladder is impalpable
§ In urinary retention, the full bladder may be palpable above the pubic symphysis and
may reach as high as the umbilicus
§ It is impossible to fee the bladders lower edge and the swelling is typically regular,
smooth, firm and oval-shaped
Percussion of the Abdomen
Percussion is used to define the size and nature of organs and masses and also detecting
fluid in the peritoneal cavity
Percussion of the Liver
§ The liver borders should be percussed to
determine the liver span
§ Start percussing from the right iliac fossa to
the right costal margin along the
midclavicular line
§ Dullness defines the liver’s lower border
§ Ask the patient to hold their finger in this
position to demarcate it for you while you
are defining the upper border
§ Define the upper border of the liver by percussing along the midclavicular line from
above
§ Normally the upper level of liver dullness is
the 6 rib in the right MCL
th
§ The normal liver span is about 12.5cms
Spleen
§ Percuss from the RIF to left costal margin
Kidneys
§ We do not routinely percuss the kidneys as
there will usually be a resonant area due to
overlying gas
35
Medicine
Bladder
§ An area of suprapubic dullness may indicate the upper border of an enlarged bladder
(most commonly from urinary retention in elderly men) or pelvic mass
Assessment of Ascites: Shifting Dullness

§ If abdominal distension is present, check for
ascites: 2-3 litres of ascites are present
before this is clinically detected
§ Usually the percussion note over the
abdomen is resonant due to air in the bowel
§ When peritoneal fluid (ascites) collects, this
accumulates in the flanks due to gravity in
a supine patient
§ When 2-3 litres of ascites is present the
abdomen will be dull to percussion in the
flanks: as fluid accumulates abdominal
distension and umbilical eversion occur
§ The dullness is then detectable closer to the midline
§ If dullness is detected in the flanks then check for shifting dullness by percussing out
to the left flank until dullness is reached. Keeping your finger over this area ask the
patient to roll towards you
§ Gravity will cause the fluid to move to the right side of the abdomen (wait 15-20
seconds)
§ Percussion is repeated and shifting dullness is present if the area of dullness has
changed to become resonant
Assessment of Ascites: Fluid Thrill

§ This may be present when very large amounts of ascites are present
§ Ask the patient to place the medial edge of one or both hands on centre of abdomen
with the fingers pointing towards the feet
§ The examiner then places their hands on either side of the abdominal wall
§ The examiner flicks one side of the abdominal wall and feels the pulsation (thrill) on
the other abdominal wall
Auscultation of the Abdomen
Bowel Sounds
§ Place the diaphragm of the stethoscope just below
the umbilicus
§ Bowel sounds can be heard intermittently so if
you do not hear them straight away you should tell
the examiner that you would like to listen for up
to a minute
§ They should be described as either present or
absent
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Medicine
§ Absence of bowel sounds:

o Paralytic ileus
o Mechanical obstruction
o Mesenteric ischaemia
Bruits
§ Auscultation for renal artery bruits 2cm either side of the
midline above the umbilicus if renal artery stenosis is
detected
§ Digital rectal examination
§ Examination of the groin, hernial orifices and external genitalia
§ Examination of the lower limbs for pitting oedema
o Hypoalbuminaemia due to chronic liver disease
o Starvation /malnutrition/malabsorption
o Protein-losing enteropathy
o Right-heart failure
§ Perform relevant investigations:
o Bedside: Urinalysis, glucose fingerprick
o Bloods: FBC, LFTs, RFTs
o Imaging: US abdomen, erect CXR
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4. Clinical Examination of a Stoma
General Inspection
§ General appearance, comfortable and breathing
§ BMI
§ Colour e.g. jaundice, pallor, slate grey, bruising
§ Obvious scars
§ Devices e.g. oxygen, IV access, ECG stickers, catheter bag, stoma, NPO
signs/specific diet, PEG tube, fluid restriction
§ Exposure and positioning: From nipple to knee/pubic symphysis, lying flat with 1
pillow for comfort
Close Inspection
§ Site
§ Spout
§ Number of lumens
o Single
o Double
§ Effluent
o Semi-solid effluent
o Hard stool
o Urine
o Comment whether any blood
§ Surrounding skin quality
o Peristomal skin inflammation/erythema
o Duskiness
o Necrosis
o Gangrene
§ Complications
o Haemorrhage
o Retraction
o Prolapse
o Stenosis (offer to digitise the stoma with a
lubricated fingertip)
o Necrosis
o Parastomal hernia (place two hands around the stoma and ask the patient to
cough)
o High-output stoma
o Obstruction
Auscultation
§ Bowel sounds (just below umbilicus) – to assess for high-tinkling bowel sounds
which may indicate obstruction
§ Perform a full gastrointestinal examination
§ Examine the hernial orifices and external genitalia
§ Check the stoma output chart
40
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Medicine
5. Clinical Examination of a Hernia
General Inspection
§ Alert, well and comfortable
§ Signs of raised intra-abdominal pressure
o Increased body habitus
o Chronic cough
§ Devices around the bed e.g. inhalers (COPD px ?)
§ Obvious scars
§ Positioning and exposure
o Supine at 45/then standing
Close Inspection
(Px Standing):
§ Obvious masses
§ Cough
(Px Supine):
§ Skin of abdomen: Hair loss, signs of steroid use e.g. straie/purpura
§ Scars
§ Raised head to the chin – check for obvious masses
Palpation
§ Get down to knee (px level at bed)
§ Superficial then deep palpation – 9 regions of the abdomen
§ Start on the normal side
§ Move to affected side
§ Describe the lump:
o Site (approximate to other anatomical structures)
o Size (estimate between the hands)
o Skin
§ Intact
§ Erythema
§ Trauma/scars
§ Signs of necrosis/gangrene
§ Tethering
o Surface
o Palpate for:
§ Temperature
§ Thrill
§ Texture
§ Establish:
o Location to the pubic tubercle:
§ Inguinal hernia: Above and medial to the PT
§ Femoral hernia: Below and lateral to the PT
o Establish where it is reducible or not:
§ Ask px can they reduce it themselves
o Establish relationship to the deep ring:
§ Deep ring is 2cm above the mid-inguinal point, midway between the
ASIS and pubic symphysis
§ Occlude the deep ring
§ Ask the px to cough
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Medicine
§ If the hernia reappears, it is a direct hernia (protruding through

Hasselbach’s triangle)
§ If the hernia does not reappear, but there is a positive cough impulse,
it is an indirect hernia
o Extension to the scrotum:
§ Usually occurs in an indirect inguinal hernia
§ Try to ‘get above’ any scrotal swelling (if possible, swelling is not a
hernia)
Auscultation
§ Mass for bowel sounds
§ Abdomen for bowel sounds (high-tinkling indicates bowel obstruction)
§ Examine the contralateral side
§ Perform a full GI examination to look for a cause of raised intra-abdominal
pressure
§ Perform relevant investigations:
o US abdomen
o CT abdomen
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Medicine
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46
Medicine
CHAPTER 4
NEUROLOGY
47
Medicine
6. Neurological Examination of the Upper Limb
General Inspection
§ Alert, breathing and comfortable
§ Obvious neurological deficit
§ Abnormal movements or posturing
§ Devices e.g. Mobility aids, hoists
§ Exposure: Seated with upper limb fully exposed
Close Inspection of the Upper Limb
§ Scars
§ Asymmetry
§ Abnormal posture e.g. Erb’s palsy,
Klumpke’s, UMNL palsy (shoulder
adducted, elbow/wrist flexed,
pronated)
§ Muscle wasting
§ Fasciculations: Irregular contractions
of small areas of muscles which have
no rhythmical pattern
§ Involuntary movements e.g. tremor
§ Skin lesions e.g. neurofibromatosis
Motor Examination
Tone
Tone
§ Tone is the assessment of the freedom of movement of a joint when moved passively
§ Described as:
o Normal
o Reduced/hypotonic (LMNL)
o Increased/hypertonic ((UMNL)
§ Assessment of tone:
o Ask the px if they are in any pain
o Take the hand as if to shake it, holding the full weight of the arm at the
forearm
o Pronate and supinate the forearm, then roll the hand around the wrist (test 2
planes)
o Hold the forearm and the elbow, moving the arm through a full range of
flexion and extension at the elbow
o Repeat for the opposite side and compare
§ Pathologies:
o Hypertonia: UMNL
o Hypotonia: LMNL
o Cogwheel rigidity (Parkinsons)
o Leadpiping (Parkinsons)
Pronator Drift
§ Ask the patient to hold out both hands with the arms extended and the eyes closed
§ Watch the arms for evidence of drifting [movement of one or both arms from the
initial neutral position]
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Medicine
o Downward drift: UMNL; the drift is caused by muscle weakness, and starts
distally with the fingers and spreads proximally
o Upward drift: Cerebellar disease; the drift is caused by hypotonia
o Loss of proprioception: Drift is due to loss of sense of joint position and can
be in any direction
Power
§ Power is a measure of muscle strength
§ Age, gender and build should be taken into account
§ Power is tested by comparing the examiners strength against the patients full
resistance
§ Grading of power:
Grade Characteristics
5 Normal power, full power against resistance
4 Reduced power, able to move against some resistance
3 Unable to move against resistance, able to move against gravity
2 Unable to move against gravity
1 Visible flicker of muscle contraction
0 Complete paralysis
Shoulder
§ Abduction (C5, C6)
o The patient should abduct the arms with the elbows flexed and resist
examiners attempt to push them down
§ Adduction (C6, C7, C8)
o The patient should abduct the arms with the elbows flexed and not allow the
examiner to push them up
Elbow * Remember to support the shoulders to properly assess the power at elbow on each
side
§ Flexion (C5, C6)
o With one hand on the shoulder and the elbow flexed try to straighten the
elbow asking the patient to resist the movement
§ Extension (C7, C8)
o With one hand on the shoulder and the elbow flexed try to bend the elbow
asking the patient to resist you.
Wrist
§ Flexion (C6, C7)
o With arms outstretched and supporting the wrist from above ask the patient
to flex the wrist and not let the examiner straighten it
§ Extension (C7,C8)
o With arms outsrtetched and supprorting the wrist from above ask the patient
to extend the wrist and not to let the examiner bend it
Hands
§ Flexion (C7, C8)
o Hold patients hand out with fingers straight supporting wrist with one hand
push up on the MCP and ask patient to resist
§ Extension (C7, C8)
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Medicine
o Hold patients hand out with fingers straight supporting wrist with one hand
push down on the MCP and ask patient to resist
§ Abduction (C8,T1)
o Hold patients hand out with fingers spread apart support hand at wrist and try
to push fingers together asking patient to resist
§ Adduction (C8,T1)
o Ask patient to hold piece of paper between ring and middle finger and
examiner tries to pull peice of paper out using same fingers on same hand ask
the patient to resist
§ Thumb abduction (C7,T1)
o With thumb held up try to push it down and ask patient to resist
§ Thumb adduction (C7,T1)
o With thumb held up try to push it up towards ceiling and ask patient to resist
§ Pincer grip (Ulnar nerve C8,T1)
o Bring thumb and index finger together in 0 sign and ask patient to resist
examiner pulling them apart
§ Grip strength (C5,T1)
o Place your index and middle finger in palm of patients hand and ask them to
grip your fifplngers and don't let you pull them out
Reflexes
§ The sudden stretching of a muscle usually evokes brisk contraction of that muscle or
muscle groups
§ Technique:
o Use the whole length of the hammer, with the end covered within the palm
o Let the hammer swing
o Make sure the patient is relaxed and resting comfortably
§ Grading of reflexes:
0 Absent
+ Present but reduced
++ Normal
+++ Increased/possibly normal
++++ Greatly increased +/- clonus
1. Brachioradialis/Supinator (C5,C6)
§ With the elbow flexed place
index and middle finger of
non dominant hand over
lower radius just above
wrist, strike the tendon
hammer onto fingers
§ Causes contraction of
brachioradialus muscle and
elbow flexion
2. Biceps (C5,C6)
§ With the elbow partially
flexed and relaxed, find the
biceps tendon
§ Place forefinger of non dominant hand on it and strike tendon hammer onto finger
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Medicine
§ Contraction of the biceps muscle occurs and flexion of the forearm

§ The tendon hammer should be held distally
§ If the biceps jerk is absent, test again using a reinforcement manoeuvre
§ Ask the patient to clench their teeth
tightly as you let the tendon hammer
fall (Jendrassik manoeuvre)
3. Triceps (C7,C8)
§ With the elbow partially flexed,
isolate thte triceps tendon
§ Strike the tendon hammer directly or
as in the video onto index finger,
causing contraction of the triceps
muscle and extension of the forearm
Remember to compare sides for each reflex
Co-Ordination
1. Finger-Nose Testing
§ Ask the patient with their index finger to touch their nose and then the examiners
finger (the target)
§ Make sure they have to fully stretch their finger before reaching the target
§ Repeat several times in different planes
§ Compare sides
§ Pathologies:
o Intention tremor: Increase in tremor as target is approached (cerebellar
disease)
o Past pointing: Overshooting of target (cerebellar disease)
2. Dysdiadokinesis
§ Ask the patient to pronate and supinate their hand on the dorsal surface (in the video
the the palmar surface is used but the dorsum is more widely accepted) of the other
hand as rapidly as possible
§ Demonstrate this as the instruction is too difficult to follow
§ This movement is slow and clumsy in cerebellar disease and is called
dysdiadochokinesis
3. Pronator Drift
§ Ask px to stretch the arms out in front of them, palms facing upwards
§ “Close your eyes and keep your arms there”
§ Positive test: Downward drift and pronation of the hand e.g. stroke causing weakness
Sensory Examination
Touch
Light Touch
§ Use cotton wool to test for light touch
§ Ask the patient to close their eyes
§ Initially touch the anterior chest wall (normal area) and ask the patient:
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Medicine
o “Can you feel that?”

o “Does it feel soft?”
§ Ask the patient to close their eyes and begin
proximally on the upper arms and test each
dermatome comparing each dermatome on the
right with the left
§ Ask the patient:
o “Can you say yes whenever you feel
it?”
o “Does it feel the same on both sides?”
Sharp Touch
§ Using a sharp object (neurotip) touch the
patients anterior chest wall (normal area), this is
to demonstrate to the patient how it feels sharp
§ Ask the patient to close their eyes and begin
proximally on the upper arm and test each
dermatome comparing each dermatome on the right with the left
§ Ask patient if they can feel object and if it feels sharp or dull
§ Map out the extent of any area of dullness; always do this by going from the area of
dullness to the area of normal sensation
§ Ask the patient:
o “Can you say yes when you feel it?”
o “Does it feel the same on both sides?”
Dermatomes of the Upper Limb:

§ C4: Above shoulder tip
§ C5: Regimental badge
§ C6: Tip of thumb
§ C7: Tip of middle finger
§ C8: Tip of little finger
§ T1: Medial mid-forearm
Temperature
Not formally assessed
Vibration
§ The base of a vibrating tuning fork (128Hz) is placed on the anterior chest wall
§ It should be explained to the patient that it is the sensation of vibration, not cold or
touch which is being detected
§ The base of the vibrating tuning fork is then placed on the dorsum of the distal
phalanx
§ The patient is asked can they feel it vibrate and to indicate when vibration stops
§ They are then asked to repeat this with their eyes closed
§ Stop the tuning fork vibrating by touching it and the patient should be able to say
exactly when this occurs
§ Compare one side with the other
§ Should vibration sense be lost or impaired distally then the tuning fork should be
moved proximally in order to establish the level at which it is normally appreciated
(ulnar head at wrist, olecranon at elbow and then the shoulders)
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Medicine
Proprioception
§ Immobilise the middle phalanx of the middle finger with one hand, holding the distal
phalanx from the sides
§ Demonstrate the position of the finger as up and down
§ Then ask the patient to close their eyes while these manoeuvres are repeated and ask
them to tell you the movement i.e. up or down
§ Repeat x 3 movements
§ If there is an abnormality, proceed to test the wrists and elbows similarly
§ Perform a full neurological examination
§ Assess the vascular integrity of the limb
o Peripheral pulses
o Capillary refill time
§ Perform relevant investigations
o Nerve conduction studies
o CT head
o MRI spine
53
Medicine
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Medicine
7. Neurological Examination of the Lower Limb
General Inspection
§ Level of consciousness
§ Breathing distress
§ Devices: Mobility aids, assistive devices, urinary catheter
§ Exposure: Supine at 45°, limb fully exposed
Close Inspection of the Lower Limb
§ Scars
§ Asymmetry
§ Abnormal posture
§ Muscle wasting
§ Fasciculations: Irregular contractions of small areas of muscles which have no
rhythmical pattern
§ Involuntary movements e.g. tremor
§ Skin lesions e.g. neurofibromatosis
Assessment of Gait*
*Before you ask px to walk, ask the examiner to accompany them for px safety
§ Ask patient to walk across the room, turn around quickly, and come back towards
you
§ Observe for:
§ Balance
o Veer off to one side = cerebellar dysfunction (e.g. disorder of left
cerebellar hemisphere will cause patient to fall to the left; diffuse disease
affecting both cerebellar hemispheres will cause generalized loss of
balance)
§ Rate of walking
o Loss of control of balance or speed = Parkinson’s
o Slow moving 2 to pain or limited range of motion in joints =
o
Degenerative joint disease

§ How do they hold their arms and legs?
o Loss of movement, evidence of contractures = post-stroke
§ Gait disorders:
o Hemiplegia: Foot is plantar flex and leg is swung in a lateral arc
(circumduction)
o Spastic paraparesis: Scissors gait (seen in multiple sclerosis)
o Parkinson’s disease: Shuffling, hesitation, freezing, festinating,
propulsion, retropulsion
o Cerebellar: Wide-based (to avoid falling); staggering towards affected
side
o Foot-drop: High stepping gait due to damage to common peroneal nerve,
which is injured by trauma to head of the fibula
o Proximal myopathy = waddling gait
o Trendelenburg’s gait: Damaged superior gluteal nerve on contralateral side
to hip dip
§ Heel-to-toe walking:
o Ask the patient to walk with the heel to the toe
56
Medicine
o Difficulty: Midline cerebellar lesion, or in older patients (Even in the absence

of neurological disease)
§ Walking on toes:
o Impossible with S1 lesion
§ Walking on heels:
o Impossible with S5 lesion causing foot drop
§ Proximal myopathy:
o Ask the patient to sit down in a chair, cross their arms in front of them and
then stand up
o Impossible with L4 lesion
o Tests for proximal myopathy
Motor Examination
Tone
§ Check the patient is not in pain
§ Described as:
o Normal
o Increased/hypertonic (UMNL)
§ Hip tone: With the patient lying on a couch, place your hands above and below the
knee and roll the leg on the couch (hip tone), this should occur without resistance
§ Knee tone: Then place one hand under the knee and abruptly pull upwards causing
flexion, then allow it to fall onto the bed (knee tone)
§ Compare sides
Ankle Clonus:
§ Clonus is a sustained rhythmical contraction of the muscles when put under sudden
stretch
§ It is due to hypertonia from an UMN lesion such as stroke
§ By sharply dorsiflexing the foot if clonus is present recurrent ankle plantar flexion
occurs
§ Ankle clonus: ≧3 beats is pathologica
Power
§ A measure of muscle strength
§ Age, gender and overall fitness of patient should be considered
§ Grading of power:
Grade Characteristics
5 Normal power, full power against resistance
4 Reduced power, able to move against some resistance
3 Unable to move against resistance, able to move against gravity
2 Unable to move against gravity
1 Visible flicker of muscle contraction
0 Complete paralysis
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Medicine
Hip
§ Flexion (L2, L3)
o Ask patient to lift up their straight leg
o Place your hand on the leg above the knee and attempt to push the leg down
asking the patient not to let you push it down
§ Extension (L5,S1, S2)
o Ask the patient to keep the leg down and not to let you pull it up
Knee
§ Flexion (L5,S1
o Ask the patient to bend the knee and not to let you straighten it.
§ Extension (L3,L4)
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Medicine
o With the knee bent ask the patient to straighten the knee and not to let you
bend it
Ankle
§ Dorsiflexion (L4,L5)
o Ask the patient to bring the foot up and not to let you push it down
§ Plantar flexion (S1,S2)
o Ask the patient to push the foot down and not to let you push it up
Toes
§ Plantar flexion (S1,S2)
o Ask the patient to plantar flex the big toe and not to let you push it up
§ Dorsiflexion(L4,L5)
o Ask the patient to bring the big toe up and not to let you push it down
Reflexes
Make sure the patient is resting comfortably.
1. Knee Jerk (L2,L3, L4)

§ Slide the left arm under the knees so they are slightly
bent and supported
§ The tendon hammer is allowed to fall on to the
infrapatellar tendon
§ Contraction of the quadriceps causes extension of the
knee
§ If the knee jerk appears to be absent it should be tested
again following a reinforcement manoeuvre
§ Ask the patient to interlock the fingers and then to pull
apart hard at the moment before the hammer strikes the
tendon (Jendrassik's manoeuvre)
2. Ankle Jerk (S1, S2)

§ Have the foot slightly flexed at the ankle with the knee bent and thigh externally
rotated
§ The hammer is allowed to fall on the Achilles tendon
§ The normal response is plantar flexion of the foot with contraction of the
gastrocnemius muscle
3. Plantar Reflex (L5, S1, S2)

§ Using a blunt object (not the tip of a tendon hammer), draw slowly
along the lateral border of the foot from the heel towards the big toe
until a response is elicited
§ The normal response is flexion of the big toe at the
metatarsophalangeal joint
§ The extensor response is abnormal [Babinski response] and indicates
an upper motor neuron lesion)
Co-Ordination
Heel-to-Shin Test
§ Ask the patient to place one heel on the opposite knee and to slide the heel accurately
down the front of the shin to the ankle
§ Then ask px to bring the heel back to the knee and repeat action
59
Medicine
§ You may need to demonstrate this, or place the patient legs into the correct starting
position
§ In cerebellar disease the heel wobbles and may fall off shin
Sensory Examination
Touch
Light Touch
§ Initially touch (do not drag as it moves
hair fibres) the anterior chest wall
(normal area); this is to demonstrate to
the patient how it feels
§ Ask the patient to close their eyes and
begin proximally on the upper leg and
test each dermatome (the area of skin
supplied by a vertebral spinal segment)
comparing right with left
§ Ask patient to say ‘yes’ every time they
feel something
§ To demonstrate whether it is
dermatomal or not in distribution, track
with cotton wool (peripheral
neuropathy is non-dermatomal in
origin, so they will have some loss of
sensation in one area and preserved
sensation in another within the same
dermatomal distribution)
Sharp Touch
§ Using a neurotip, touch the patient
anterior chest wall (normal area) to demonstrate to the patient how it feels sharp
§ Ask the patient to close their eyes and begin proximally on the upper leg and test
each dermatome comparing right with left
§ Map out the extent of any area of dullness
§ Always do this by going from the area of dullness to the area of normal sensation
Dermatomes of the Lower Limb:

§ L2: Antero-medial mid-thigh
§ L3: Above the knee
§ L4: Medial malleolus
§ L5: Dorsal 1 webspace of the foot
st
§ S1: Lateral heel/small toe

Temperature
Not formally assessed
Vibration
§ Carried within the dorsal columns
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Medicine
§ The base of the vibrating tuning fork is then placed on the dorsum of the terminal
phalanx
(1 MTP joint, lateral malleolus, upper part of tibia, iliac crest, costal margin)
st
Proprioception
§ Grasp the distal phalanx from the sides and move it up and down to demonstrate
these positions to the patient
§ Then ask the patient to close the eyes while these manoeuvres are repeated and ask
them to tell you the movement i.e. up or down (max 5mm in the feet, in the finger
1mm – this is how sensitive our ability to test proprioception should be)
§ If there is an abnormality, proceed to test the ankles and knees similarly
o Spastic paraparesis: Examine for sensory level on the thorax
o Flaccid paraparesis: Perform DRE and examine for saddle anaesthesia
§ Assess the vascular integrity of the limb
o Peripheral pulses
o CT head
o MRI spine
61
Medicine
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Medicine
8. Clinical Examination of the Gait and Cerebellum
General Inspection
§ Alert
§ Breathing
§ Colour
§ Abnormal posture – e.g. hemiplegic positioning
§ Devices – assistive devices, mobility aids
§ Exposure: Ensure that the patient’s legs are exposed and clearly visible
Close Inspection of the Lower Limbs
§ Asymmetry
§ Muscle wasting or hypertrophy
§ Abnormal movements:
o Tremor: Regular, rhythmic contractions and relaxations of a muscle
o Fasciculations: Irregular contractions of small areas of muscle which have no
rhythmical pattern; if present with weakness and wasting, fasciculation
indicates degeneration of the lower motor neuron e.g. MND
o Myoclonic jerks
o Other involuntary movements (dyskinesias) e.g. dystonia, chorea, athetosis,
ballism, tics
Examination of the Gait and Ataxia*
*Before you ask px to walk, ask the examiner to accompany them – VERY IMPORTANT
FOR PX SAFETY
Truncal Ataxia
§ Ask the patient to sit with
their arms crossed across
the chest at the side of the
bed
o Positive test: Loss of
balance is indicative
of truncal ataxia
§ Ask patient to stand (only if
stable sitting)
o Positive test: Loss of
balance is indicative
of truncal ataxia
Ataxic Gait
§ Ask patient to walk across the room, turn around quickly, and come back towards
you
§ Observe for features of cerebellar gait:
o Broad-based gait
o Lateral veering (towards affected side; diffuse disease affecting both
cerebellar hemispheres will cause generalised loss of balance)
o Irregular steps
§ Gait disorders:
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Medicine
o Hemiplegia: Foot is plantar flex and leg is swung in a lateral arc

(circumduction)
o Spastic paraparesis: Scissors gait (seen in multiple sclerosis)
§ Heel-to-toe walking:
o Ask the patient to walk with the heel to the toe
o Difficulty: Midline cerebellar lesion, or in older patients (Even in the absence
of neurological disease)
Romberg’s Test
§ Test for sensory ataxia i.e.
non-cerebellar
§ Ask the patient to stand with
feet together, first with eyes
open and then closed
§ Stand close to the patient in
the case of fall
§ Inspect for:
o Unable with eyes open
or closed, seen in
cerebellar disease
o Positive Romberg’s Test: Loss of balance with eyes closed (sensory ataxia),
seen with impaired proprioception due to pathology affecting the posterior
dorsal columns
Examination of the Cerebellum
Pathologies:
§ Generally, cerebellar lesions cause ipsilateral cerebellar signs
§ Bilateral cerebellar lesions will cause bilateral signs
§ Central cerebellar lesions can cause bilateral, asymmetrical signs
General Inspection
§ Consciousness
§ Hearing aid
§ Asymmetry
§ Involuntary movement
§ Rash àSkin (vasculitis, neurofibromas, café au lait spots)
§ Scars
§ Abnormal posture or gait
§ Walking aid
Head and Neck
Nystagmus
§ Jerky horizontal nystagmus towards side of the cerebellar lesion
§ Test vision in ‘H’ pattern
§ Inspect for:
o Loss of saccadic eye movements
o Nystagmus (hold at each point to examine for nystagmus)
Speech
§ Test for dysarthria:
o Ask an open-ended question to hear the patient speak e.g. staccato speech
o Difficulty articulating speech e.g. jerky, slurring, explosive, loud, with
irregular separation of syllables (sign of diffuse cerebellar involvement)
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Medicine
§ Ask patient to say “British Constitution” or “West Register Street” e.g. slurring of
speech
Upper Limbs
Pronator Drift
§ Ask patient to extend their arms to shoulder level out in front of them, palms
upwards:
o Upward drift = cerebellar lesion
o Pronator drift (palms pronate) = contralateral pyramidal tract defect/ upper
motor neuron lesion
§ Abnormalities more pronounced if hands tapped and/or eyes closed
o Downward drift = lower motor neuron lesion
Rebound
§ Ask patient to raise their arms quickly from their sides, and stop suddenly mid-
motion:
o Inability to stop = rebound = loss of coordination between agonist and
antagonist muscle action
Tone
§ Described as:
o Normal
o Increased/hypertonic ((UMNL)
§ Assessment of tone:
o Ask the px if they are in any pain
o Take the hand as if to shake it, holding the full weight of the arm at the
forearm
o Pronate and supinate the forearm, then roll the hand around the wrist (test 2
planes)
o Hold the forearm and the elbow, moving the arm through a full range of
flexion and extension at the elbow
o Repeat for the opposite side and compare
§ Pathologies:
o Hypertonia: UMNL
o Hypotonia: LMNL
o Cogwheel rigidity: Parkinsons
o Leadpiping: Parkinsons
Co-Ordination
§ Past-Pointing/Intention tremor:
o Ask patient to move their index finger
between their nose and your finger, reposition your finger after each touch;
test both hands! Ensure patient must fully extend elbow to reach your finger
o Past pointing = ipsilateral cerebellar disease
o Intention tremor = ipsilateral cerebellar disease
§ Dysdiadochokinesis:
o Ask patient to rapidly and repeatedly touch the palm and then dorsal side of
one hand against the palm of the other hand; test both hands!
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Medicine
o Inability (not fast or accurate): Dysdiadochokinesis (ipsilateral cerebellar

disease)
§ Rapidly alternating finger movements:
o Ask patient to touch the tip of each finger to the thumb of the same hand
o Test both hands
o Inability (not fluid or accurate): Dysdiadochokinesis (ipsilateral cerebellar
disease)
Lower Limbs
Tone
§ Check the patient is not in pain
§ Described as:
o Normal
o Increased/hypertonic (UMNL)
§ Hip tone: With the patient lying on a couch, place your hands above and below the
knee and roll the leg on the couch (hip tone), this should occur without resistance
§ Knee tone: Then place one hand under the knee and abruptly pull upwards causing
flexion, then allow it to fall onto the bed (knee tone)
§ Ankle tone: Then move the ankle joint in a circular fashion
§ Compare sides
Co-Ordination
§ Heel-to-Shin Testing:
o Ask patient to move the heel of one foot up and down along the top of the
other shin; test both feet!
o Inability (not fast or straight) = loss of coordination = ipsilateral cerebellar
disease
§ Toe-to-Finger Testing:
o Ask patient to lift the big toe up to touch your finger; test both feet!
§ Past pointing
§ Intention tremor
§ Assess the vascular integrity of the limbs
o Peripheral pulses
o CT head
o MRI spine
o MRI (to visualise posterior fossa)
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Medicine
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Medicine
9. Clinical Examination of Speech
General Inspection
§ Inspect for:
o Obvious neurological deficit
o Facial asymmetry
o Abnormal posturing or movements
o Devices: Hearing aids, mobility aids or medications
§ Ask the patient:
o “Which hand do you write with?”
§ Dysphasia can only occur in a dominant lobe pathology
§ Offer MMSE
General Assessment of Speech
§ Ask the patient
o “Could you tell me what you did yesterday?”
o “Could you tell me how many grandchildren you have and their names?”
§ Assess the speech for fluency and appropriateness:
o Volume
o Rate
o Rhythm
o Modulation
o Content
o Fluency
Examination for Dysarthria
§ Repeat the following phrases after me*:
o “Baby hippopotamus”
o “Yellow lorry”
o “West register street”
*Look at tongue palatal movement, to examine for issues with movements of mouth and
phonics in relation to motor command
§ Repeat the following sounds after me:
o “La-la-la”: Cranial nerve XII
o “Ga-ga-ga”: Cranial nerve IX and X + gag reflex
o “Ma-ma-ma”: Cranial nerves V and VII
§ Count from 0 to 20
o Fatiguability seen in Myasthenia Gravis
§ Offer to examine cranial nerves IX-XII
Examination for Dysphasia
Assessment for Receptive Dysphasia:
§ Perform these three commands:
o Take this piece of paper in your hand
o Fold it in two
o Place it on the table
§ Could you read this sentence?
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Medicine
Assessment for Expressive Dysphasia:

§ Could you write ‘Today is Wednesday’ on this paper?
§ Name as many words as you can beginning with the letter ‘S’
o <12 is abnormal
Assessment for Conductive Dysphasia

§ Repeat after me: “No ifs, ands or buts”
§ Can you repeat after me:
o ‘School’
o ‘Register’
o ‘Ninety-seven’
*May mix up the words or mispronounce them, indicating a deficit originating within the
arcuate fasciculus
Assessment for Nominal Dysphasia:

§ Could you name these three objects for me?*
o Watch
o Pen
o Tie
*If they cannot name the object, ask them what it does
§ Take a full clinical history
§ Perform a full neurological and cranial nerve examination
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Medicine
Common Speech Pathologies

Tests for Speech Apraxia (Receptive Dysphasia):
If patient is not able to do the action when being asked, she may have a language
processing issue e.g. receptive dysphasia
Prove this by showing her the motor function. If patient can mimic the action when you
perform it, it suggests that the problem is related to language
If the patient cannot mimic the action when you perform it, it suggests that the problem
may be related to either a language or a praxis problem – need to differentiate between
the two
Praxis is the ability to execute motor actions
Dysphasia is the inability to execute or interpret language and sound
Test for Conductive Dysphasia

If there is difficulty in repeating these sentences, the patient may have a conductive
dysphasia
• “No ifs, ands or buts”
• Could you perform this action for me?
o Combing hair e.g. speech apraxia
o Could you touch your head with your hand please?
• Problems with speech:
o Bulbar palsy
o Pseudobulbar palsy
o Apraxia
o Dysphasia
o RSA advert: Cerebellar speech with social worker
• Characteristics of speech:
o Quality (intelligible, fluent, appropriate, comprehensible)
o Quantity (alogia, poverty of speech) – may be caused by MND secondary to
muscular disease caused by denervation (causes alogia), MG causes
fatigability leading to alogia also
o Pitch
§ E.g. Bilateral UMNL CN9-11 causing pseudobulbar palsy – high-
pitched voice ‘Donald Duck’
§ E.g. MG – unsustained pitch due to fatigability
§ E.g. Parkinsons – low pitch, low volume
o Volume
o Modulation
§ Poor modulation occurs in denervation/extrapyramidal disease e.g.
Parkinsons, MND
§ Abnormal modulation: Staccato speech e.g. cerebellar speech
o Rate
o Rhythm
§ Staccato speech caused by cerebellar disease
Reporting Back:
§ Comment on quality, quantity, pitch, tone, modulation, rate and rhythm
§ Good orientation in time, person and place
§ With reagrds to her speech, it was fluent and intelligible
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Medicine
§ She had normal modulation, tone and pitch, and her rhythm was appropriate
§ With regards to word finding and naming, she had some difficulty with this but
overcame this with circumlocution
§ In addition, there were some nominal difficulties e.g. unable to repeat some phrases.
This appeared to be isolated to a CNIX/X as her main issue related to repetition of
‘ga’. I would like to perform a full cranial nerve examination and examine the gag
reflex
§ Relevant negatives: Neologisms, paraphasias, echolalia, circumlocution
§ In summary, the speech was intelligible and fluent, with some word finding
difficulty. This indicates no receptive or expressive dysphasia, but this indicates a
nominal dysphasia
Classic Speech Abnormalities
1. Receptive dysphasia (Wernicke’s area)

• Minimal understanding of the written or spoken word
• Fluent manner of speech which is garbled and inappropriate, often with neologisms
(new words)
• Normal level of fluency, rate and rhythm e.g. baby babbling, but what comes out is
unintelligible
2. Expressive dysphasia
• Affects Broca’s area
• Full understand speech, but difficulty in fluent and organized speech
• Capable to respond appropriately to you, but not in the fluent manner of someone
with normal speech
• Almost everyone who has expressive dysphasia also have nominal dysphasia, but
people who have nominal dysphasia don’t necessarily have expressive dysphasia
• Use correct words and phrases
• Rhythm abnormalities, hesitation, stuttering
• Impaired fluency
• Hesitant
• Stuttering
• Frustration due to inability to communicate
• Tone, pitch and modulation tend to be unaffected, unless px has a PICA syndrome
where they have UMN pseudobulbar palsy features
• Paraphasia (e.g. show them a watch and they say ‘clock’), echolalia (repetition of
the last syllable or phrase e.g. Tourettes syndrome, schizophrenia, autistic
spectrum)
• Circumlocution e.g. Show them a pen and they say ‘you use that to write’
3. Nominal dysphasia
• Affects the arcuate fasciculus – area between Brocas and Wernickes)
• Characteristics:
o Word-finding difficulty
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Medicine
o Circumlocution e.g. ‘something that you write with and there is ink in it’ –
using a long descriptive sentence to describe an object
4. Conductive dysphasia
• Difficulty in repeating a sentence/phrase
• If they come to a sentence themselves they have no problems with it
Syndromes Associated with Speech Deficits
1. Bulbar Palsy Speech:
• Subtype of MND, progressive neurological disease affecting the anterior horn cell
• Bulbar: Cranial nerves IX – XII bilaterally
§ Quality reasonable
§ Nasal/slurred in nature
§ Poor modulation
§ Low volume
§ Low pitch
2. Parkinsons Disease:
§ Quality of speech is fine
§ Low volume, low pitch
§ Monotonous, poor modulation
3. Myasthenia Gravis:
§ Unsustained speech secondary to fatiguability
§ Low volume – not releasing enough ACh, effort for speech increases
4. Pseudobulbar Palsy e.g. MND, stroke
§ ‘Donald duck’ spastic speech
§ Quality is reasonable
§ Comprehensible
§ Quantity is low
§ High pitch, poor modulation, low volume
Orofacial Dyspraxia
May be caused by congenital facial anomalies
e.g. Can you show me how you would blow up a balloon?
§ Inability of execution of a motor command
e.g. dropping consonants at the beginning of words
e.g. intact understanding, speech is non-fluent
Ddx for Dysarthria: (Cerebellar or local disease)

• Cerebellar
o Global cerebellar disease e.g. phenytoin toxicity, alcohol toxicity
(temporarily and acutely) – most common
o Cerebellar infarction
o Cerebellar tumour
• Local
o Mouth ulcers
o ENT cancer
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Medicine
o Local cranial nerve disease e.g. bilateral pseudobulbar palsy (denervation +

muscular weakness, also involving speech)
o Congenital abnormality e.g. cleft palate
o Trauma
o Retrosternal goitre (compressing onto pharyngeal nerve/airway) – more
likely to be decreased volume of voice
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Medicine
10. Clinical Examination of Higher Order Functioning
General Inspection
§ Alert, well and responsive
§ Facial asymmetry
§ Abnormal movements or posturing
§ Devices around the bed e.g. hearing aids, mobility aids, medications
Frontal Lobe
Executive Function
§ “Could you show me how you brush your teeth?”
§ “Could you talk me through how you would make a piece of toast?”
§ Motor function:
o Side of hand
o Make a fist
o Palm flat on table
§ Go-no-go test
Primitive Reflexes
§ Ask the patient to place their hands on the table, palms up
§ Ask the patient a question e.g. “Do you have any children? What are their names?”
§ Place a finger into the palm – examine for grasp reflex
Abstract Thinking
§ “Interpret this proverb: A bird in the hand is worth two in the bush”
§ “Explain to me how you would get to the bus from here”
§ “Name as many animals as you can beginning with the letter ‘C’”
§ Stroop test – “Could you tell me the colour of this word?”
Additional Symptoms
§ “Have you noticed any rapid changes in your mood lately?”
§ “Have you had any fits or seizures?”
§ “Have you had any trouble controlling your waterworks?”
§ Examine the remaining lobes of the brain
§ Take a collateral history
Parietal Lobe
Dominant Lobe Deficit: Gerstmann Syndrome
§ Acalculia
o “What is 2+5?”
o “Count backwards from 100 in 7s”
§ Agraphia
o “Could you write your full name and address please?”
§ L-R disorientation
o “Show me your left hand”
o “Bring it to touch your right heel”
§ Finger agnosia
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Medicine
o “Show me your thumb”

o “Show me your little finger on the other hand”
Non-Dominant Lobe Deficit

§ Spacial neglect
o “Could you draw a clock face for me?”
§ Constructional apraxia
o “Could you draw a house for me?”
§ Dressing apraxia
o “Could you take off your jumper and put it back on for me?”
Non-Localising Deficit
§ Visual inattention
o “Could you hold both hands out in front of you?”
o “Can you see both hands?”
§ Sensory neglect
o “Can you feel this cotton wool? Does it feel the same on both sides?” (test
one side individually, then both together)
§ Astereoagnosia
o “Keep your eyes closed, and place your hand palm facing upwards”
o Place an object into patients palm
o “Can you tell me what you think this object is?”
§ Two-point discrimination
o With neurotips 1cm apart
§ Visual fields
o Examine for lower quadrantanopia
Temporal Lobe
Assessment of Memory
§ “What age are you?”
§ “Remember and repeat this address after me: 123 St. Stephens Green”
“Remember and repeat these three words: Orchid, lily and rose”
§ “Remember and repeat this name after me: James Bond”
§ “Do you know when World War 2 ended?”
§ “Do you know who the President of Ireland is?”
Assessment of Recall
§ “Can you repeat back everything I’ve asked you today?”
Additional Symptoms
§ “Have you had any recent problems with your vision?”
§ “Have you had any fits or seizures?”
§ Examine the remaining lobes of the brain
§ Take a collateral history
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Medicine
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Medicine
11. Clinical Examination for Parkinson Disease
General Inspection
§ Obvious neurological deficits
§ Loss of facial micro-movements/‘mask-like’ facial
appearance
§ Flexed extrapyramidal posturing
o Cannot lie flat (head held off pillow)
o Simian posture on standing
§ Stooped
§ Hands in front of groins
§ Devices e.g. mobility aids, medications
§ Positioning: Ideally supine at 45°, majority can be done
seated
Examination of the Gait

§ Ask the patient to stand – examine for stability
§ Ask the examiner to accompany if concerns for safety
§ Ask the patient to walk from one side of the room to the other
§ Signs of Parkinson’s disease:
o Stooped posture
o Difficulty initiating movement
o Freezing
o Festinating gait
o Loss of arm swing (usually also the side which is affected by tremor)
o Gait-activated tremor
o Reduced stridal length
o Circumferential turning
Examination of Speech and Nystagmus
Examination of Speech
§ “Can you repeat after me – ‘West Register Street’”
§ Assess for:
o Slow, monotonous speech
o Hypomimia
Examination of the Upper Limb
Rebound
§ “Close your eyes and bring both of your arms straight up from your sides to stop at
shoulder level”
§ Ask patient to extend their arms to shoulder level out in front of them, palms
upwards:
o Upward drift: Cerebellar lesion
o Downward drift: LMNL
o Pronator drift (palms pronate): Contralateral pyramidal tract defect/UMNL
§ Abnormalities more pronounced if hands tapped and/or eyes closed
Examination for Tremor

§ “Place your hands palms up on the table please”
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Medicine
§ Examine for pill-rolling, coarse tremor (3-4 Hz)

§ Assess for improvement:
o “Could you spread your fingers wide for me?”
o Tremor of Parkinson’s disease should improve
§ Assess for intention tremor:
o “Could you bring your index finger to your nose, then straighten your arm
and reach out to touch my finger?”
o Tremor should resolve with intentional movement
§ Assess for flapping tremor
o “Hold your arms straight out as if stopping a bus”
o “Close your eyes”
o Push back on each hand and assess for flapping tremor – to rule out other
causes of a tremor
Tone
§ “Give me the full weight of your arm”
§ Assess for hypertonicity by passive movement of both upper limbs through a range
of movements
o Cog-wheel rigidity
o Supinator catch
§ Kineer-Wilson sign:
o Ask the patient to tap on their knee with the left hand whilst you examine
for hypertonicity in the right
o Positive Kineer-Wilson sign: Reinforcement of hypertonicity
Examination of Bradykinesia/Functional Movements of the Hand

§ “Can you pretend that you are playing the piano?”
§ “Can you repeatedly open and close your fist as quickly as you can?”
§ “Can you show me how you might pick up a key?”
§ “Can you show me how you would change a lightbulb?”
Special Tests
Examination of Handwriting
§ Ask the px to write their full name and address on a
piece of paper /copy circular scribble
§ Assess for micrographia/functional difficulty
Examination of Speech
§ Ask patient to state their name and date of birth
§ Listen for slow, monotonous speech
Examination for Glabellar Tap

§ Ask the patient to focus on a point on the wall in front
of them
§ Tap with the forefinger between the eyes
§ Assess for loss of attenuation of the blink response associated with Parkinson’s
Disease
Examination for Progressive Supranuclear Palsy (Vertical Gaze Palsy)

§ Ask the patient to keep the head still
§ Hold your finger horizontally in front of the face
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§ Bring the finger upwards

§ Assess for vertical gaze palsy associated with Parkinson’s Plus Syndrome (PSP) by
observing the movement of the eyelids
Assessment for Axial Rigidity

§ “Do you mind if I move your neck?”
§ Approach from the side/behind
§ Ask about pin
§ Move the head to the left and right to assess for PSP
§ Perform full neurological examination
o Erect and supine BP (Shy-Drager syndrome)
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12. Clinical Examination of the Cranial Nerves
General Inspection
§ Abnormal movements or posturing e.g. UMNL
positioning
§ Facial asymmetry
§ Neurocutaneous lesions e.g. port-wine stain
(Sturge-Weber syndrome, associated with
aneurysms and AVMs), café-au-lait spots
(neurofibromatosis), neurofibromas (associated with optic
gliomas)
§ Scars e.g. craniotomy scars (look!), behind the ear
(cerebellopontine angle lesion, NFII)
§ Devices e.g. mobility aids, hearing aids, medications,
glasses
The 1 Nerve - Olfactory
st
§ Purely sensory nerve

§ Ask patient: “Have you noticed any change in your sense of smell or taste?”
§ If they say yes, proceed with test for anosmia:
o Coffee grounds
o Vanilla essence
o Orange rind
§ Occlude one nostril at a time and ask the patient to identify smells
§ If the answer is no, move to the second cranial nerve
2 Cranial Nerve: Optic Nerve
nd
General Screening for Visual Deficits

§ “Do you have any problems with your vision?”
§ Gross assessment of visual deficits
o “Do you have any problems with your vision?”
o “Do you wear glasses or contact lenses? Please leave them on if so”
o “Can you see my full face?”
o “Cover one eye please. Can you see my full face?” Repeat on both sides
§ Homonymous hemianopia (left/right-sided)
§ Bitemporal hemianopia
§ Binasal hemianopia (almost never seen – requires bilateral cortical
lesions)
§ Central scotoma (full face but decreased central acuity)
Visual Acuity*
*Should wear their glasses because refractive errors are not related to CNs
§ Use a Snellan chart, standing an appropriate distance from the patient
§ “Do you wear glasses or contact lenses? Please leave them on if so”
§ “Cover one eye please. Can you read the bottom line of this Snellan chart?”
o If having difficulty: How many fingers am I holding up?
o If having difficulty: Perception of hand movement
o If having difficulty: Perception of light movement
§ Reporting visual acuity:
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o Right eye
o Left eye
Visual Fields
§ Sit knee to knee with patient
§ “Could you remove your glasses please?”
§ “Please cover one eye” – if patient covers their right eye, you should cover your left
§ “Please keep your head still and keep looking at my eye”
§ Move wagging finger from the periphery towards the centre
o “Tell me when you see my finger”
o “How many fingers am I holding up?”
o Repeat x 4 times moving towards the centre of the visual field
o Repeat in all four quadrants
§ Change hands and repeat on the opposite eye
§ Defects:
o Bitemporal hemianopia
§ Optic chiasm lesion e.g. pituitary adenoma
• Outer image is usually the false image
o Unilateral field loss
§ Optic nerve lesion
§ Tumour/vascular
o Homonymous hemianopia
§ Optic tract e.g. lesion of occipital cortex
§ Tumour/vascular e.g. UMNL (stroke)
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Fundoscopy
§ Use the right eye to look in patient’s right eye and vice versa
§ Look first at the cornea, iris and lens, then look at the fundus
§ Search first for the optic disc then look at the four quadrants of the retina
§ The blind spot:
o Small area close to the centre of the visual fields where there is no vision
o This is the area where the optic disc is seen on fundoscopy and is the point
where the optic nerve joins the retina
o The blind spot enlarges with papilloedema e.g. raised ICP with brain tumour
Offer to assess for:

§ Central scotoma:
o Loss of central macular vision is tested for with a red–headed hat pin
o Move the red-headed hat pin from the temporal periphery through the central
field to the nasal periphery, asking the patient “Can you see the head of the
pin?”
E.g. demyelination of the optic nerve in M.S. can cause loss of central vision
§ Colour vision:
o Tests of colour vision are not carried out routinely
o They may reveal subtle defects of the retina or optic nerve
o Ishihara plates are used; checking patient’s eyes separately plates made up
of coloured dots containing numerical shapes are presented to patient who is
asked to discern the numbers shown in each pattern
3 [Oculomotor], 4 [Trochlear] and 6 [Abducens]
rd th th
Screening for Resting Diplopia

§ Assessment for resting diplopia:
o Place a hand on the patient’s head and hold a single finger in front of them
o “Can you see my finger there? How many am I holding up?”
§ If there is more than one image, resting diplopia is present due to
failure of unification of two images
§ Resting diplopia is an eye muscle problem; the two images projected
onto the retina are slightly out of sync as one muscle is weaker than
the other (ophthalmoplegia may cause generalised muscle weakness,
which may lead to no diplopia at all as all are weak)
§ Isolation of diplopia:
o Diplopia is an early sign of ocular muscle weakness
o If diplopia is present at rest, ask the patient “Could you close your left eye
please? How many images are there now?”
o “Which image disappeared, the image on the outside or the central image?”
§ If the peripheral image has disappeared when one eye is closed, then
that is the affected eye
§ The peripheral image is always the abnormal image (usually also
paler and less distinct)
§ Repeat on the opposite side
Examination for Eye Movements, Nystagmus and Progressive Supranuclear Palsy

Eye Movements
§ Assess for eye movement, diplopia [double vision] and nystagmus
§ “Please keep your head still and follow my finger with your eyes”
§ “Do you have any pain or double vision at the moment?”
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§ Move your finger in a H pattern, testing all movements of the eye

§ “Please let me know if you have pain or double vision at any point”
Nystagmus
§ Opposing ocular tone keeps the eyes in the midline at neutral position
§ Examination of nystagmus:
o Bring the finger 30° from neutral (testing at the extremes of vision will cause
nystagmus in a normal person)
o The direction of nystagmus is defined as that of the fast [correcting]
movement
o Slow movement away is abnormal with a fast beat in the opposite direction
to attempt to correct the tone
§ Differential diagnosis for horizontal nystagmus (accounts for the vast majority of
nystagmus):
o Congenital
o Vestibular disease e.g. Meniere’s disease (acute causes nystagmus away from
the side of the lesion, chronic causes nystagmus towards the side of the
lesion)
o Cerebellar disease (nystagmus towards the side of the lesion)
o Phenytoin toxicity
o Alcohol toxicity
o Tumours
o Multiple sclerosis
o Internuclear ophthalmoplegia: Abducting eye has greater nystagmus than the
adducting eye. There is dissociation of conjugate eye movements. It suggests
MS with a lesion in the medial longitudinal bundle
§ When there is a R-sided INO, the problem is seen when you look to
the opposite side (e.g. look to the left)
• The R eye should adduct
• Thus there will be failure of adduction
• In the L eye, there should be abduction
• Beating nystagmus
§ R-sided lesion (Ask px to look to the side which is contralateral to the
lesion):
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• Lesion is on the R side when looking left

• Failure of adduction on the right eye
§ Abduction in the left eye with nystagmus whilst looking left
§ Differential diagnosis for vertical nystagmus:
o Upwards: 4 ventricle pathologies
th
o Downwards: Foramen magnum pathologies
Progressive Supranuclear Palsy

Impairment of vertical or horizontal gaze; loss of downward vertical gaze is usually lost first
§ “Keep your head still and follow my finger with your eyes”
§ Hold your index finger above patient’s head and rapidly bring it down towards the
ground
§ Delay/inability to follow the finger in a downward vertical gaze suggests PSP
§ ‘Doll’s eye sign’: Oculocephalic reflex
o Eyes follow the direction of head rotation
o Indicative of brainstem injury
o Possible loss of gag reflex and cough reflex
Optic Reflexes
Direct and Consensual Pupillary Light Reflex*
*Ask the patient to look over your shoulder at an intermediate distance
Physiological mechanism:
Afferent limb: CNII fibres on the eye receiving the stimulus detect the light stimulus
and sends a message to both CNIII nuclei + stimulate the Edinger-Westphal nuclei
of the CNIII (parasympathetic innervation)
CNIII fibres effects the motor action (constriction) of the pupils (both eyes)
§ Inspect the pupils for:

o Size
o Shape
o Equality
o Regularity
o Oscillopsia (cerebellar disease)
§ Direct and consensual pupillary light reflexes:
o Approach the eyes from the side
o “Please keep looking straight ahead”
o Shine the light from the side (otherwise the eye will immediately
accommodate) into the right eye
o Repeat into the same eye twice and observe for:
§ Direct pupillary constriction (right eye)
§ Consensual pupillary constriction (left eye)
o Repeat with the opposite eye
§ Pathologies of the pupillary light reflex:
o If direct is absent and consensual is present, the problem is ipsilateral CNIII
o If direct is absent and consensual is absent, the problem is ipsilateral CNII
o If direct is present and consensual is absent, the problem is contralateral
CNIII
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Relative Afferent Pupillary Defect: Swinging Light Test

§ One eye has diminished afferent fibres (either in quantity or in quality) – most
commonly caused by visual acuity pathologies
§ Move the torch quickly from pupil to pupil, approaching from the side
§ The light is shone from eye to eye, and after a short period of time, test for the direct
pupillary light reflex in the affected eye will lead to paradoxical dilatation
o The eye appears to be dilated, but it is not truly dilated
o The pupil has actually failed to contract rather than truly dilated; this occurs
because afferent impulses are reduced and sluggish, and do not respond as
quickly as they should to the rapid movement of light
§ Differential diagnoses (causes of optic atrophy/severe loss of visual acuity):
o Severe visual acuity loss (most common cause)
o Retinal artery/vein thrombosis
o Temporal arteritis
o Optic neuritis
Accommodation Reflex
§ Ask px to focus on spot on the wall
§ Then focus on the pen in front of them (at the nose)
§ Checking for pupillary constriction and convergence
§ Pathologies of the accommodation reflex:
o Absent light reflex with an intact accommodation reflex occurs in Argyll
Robertson pupil in syphilis affecting the nervous system
o CNII and CNIII, involving the visual cortex (occipital lobe)
5 [Trigeminal] Nerve
th
§ This nerve contains both sensory and motor fibres

o Pons: Motor nucleus + nucleus for touch
o Midbrain: Nucleus for proprioception
o Medulla: Nucleus for pain + temperature
§ Reaches the geniculate ganglion where it splits into V1, V2 and V3 branches
Facial Sensation
§ Place cotton wool on the
sternum – to get baseline of
touch sensation
o Test high on the chest
wall because it is
highly unlikely that
there is a spinal lesion
at that high
§ Test in the three divisions of
the nerve comparing each side
with the other
o Ophthalmic: supplies
forehead, cornea and
conjunctiva (test
forehead)
o Maxillary: supplies the
middle of the face
o Mandibular: supplies the lower jaw
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Medicine
§ Ask the patient:

o “Do you feel that?”
o “Does it feel the same as it did on the chest?” – Vast majority of people with
neuropathies do not have complete loss of sensation, but an altered sensation
§ Repeat by testing for pain with sharp object in same areas
Motor Division
§ Inspect for wasting of the temporal and masseter muscles
§ Most common cause of temporalis wasting is cachexia, particularly if bilateral
§ “Could you clench your teeth please?” Palpate for contraction of the masseter
muscles
§ “Could you open your mouth and don’t let me close it?” Attempt to close it shut
(pterygoid muscles)
o Unilateral weakness of the motor division causes the jaw to deviate towards
the weak side
o If weakness is suspected patients should be asked to move the jaw laterally
against resistance
o The jaw can be moved towards the affected muscle but cannot move towards
the normal side
Jaw Jerk Reflex

§ Place fingers on chin and then tap with patellar hammer
§ Both afferent and efferent pathways are supplied by the fifth nerve
§ The patient lets his mouth fall open slightly
§ The examiners finger is placed on the jaw
§ The finger is tapped lightly with a tendon hammer
§ The reflex response comprises brisk closure of the jaw
§ It is often not visible and can be difficult to determine if it is present
Corneal Reflex
§ Lightly touch the cornea with a wisp of cottonwool
§ Reflex blinking of both eyes is a normal response
§ The afferent part of the reflex arc is the first division [ophthalmic nerve] of the fifth
nerve
§ The efferent arc is supplied by facial nerve
§ Each CNV communicates with both CNVII and therefore both eyes close when each
cornea is stimulated
Offer: Sneeze Reflex

§ Irritation of the nasal mucosa
§ Complex motor response – V, X, XI and part of the VII
§ Not done
7 [Facial Nerve]
th
Supplies:
§ Motor innervation to the muscles of facial expression, digastric, stapedius +
mylohyoid
§ Special sensory innervation for taste to anterior 2/3 of tongue via chorda tympani
Inspection
§ Facial symmetry
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Medicine
o Unilateral drooping of the corner of the mouth

o Smoothing of the wrinkled forehead
o Smoothing of the nasolabial fold
§ Ramsay Hunt syndrome: Facial nerve + deafness
(Varicella Zoster)
o If a lower motor neuron lesion is detected
[weakness on one side of face]
o Check for ear and palatal vesicles of
herpes zoster of the geniculate ganglion
(near concha of the ear in dermatomal
distribution)
§ Differentiation between upper and lower motor
neuron lesions:
o Facial sparing
o LMNL: Bell’s palsy [no sparing of the forehead – complete paralysis looks
worse than it is]
o UMNL: Stroke/tumour/MS [sparing of the forehead – partial paralysis looks
better than it is]
§ Ask the patient: “Have you noticed any sensitivity to loud noises?” (For stapedius
muscle – dampens down loud noises)
Muscles of Facial Expression

§ Temporal branch:
o “Could you look up and
don’t let me push your
eyebrows down?”
o Feel for muscle strength
by pushing down on
forehead
o This movement is
preserved on the side of
an upper motor neurone
lesion [a lesion which
occurs above the level of
the brainstem nucleus], because of bilateral cortical representation of these
muscles
o The remaining muscles of facial expression are usually affected on the side
of an UMN lesion.
o In a LMN lesion all muscles of facial expression are affected on the side of
the lesion
§ Zygomatic branch:
o “Could you shut your eyes tightly and don’t let me open them?”
o Observe and try to force open each eye
§ Buccal branch:
o “Could you blow out your cheeks? Don’t let me flatten them”
§ Marginal mandibular:
o “Could you show me your teeth?”
o Compare the nasolabial grooves which are smooth on the weak side
§ Cervical branch:
o “Could you pretend you are shaving, like me?” – for platysma
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Medicine
Special Sensation
§ Examining for taste of the anterior 2/3 of the tongue is not usually required
§ Examination:
o Salt, honey etc.
o Close your eyes
o Place unilaterally on anterior 2/3 of the tongue
o Ask them to wash out again and repeat
§ Ask the patient: “Have you noticed any changes in your sense of taste?”
Corneal Reflex
§ The afferent part of the reflex arc is the first division [ophthalmic nerve] of the fifth
nerve
§ The efferent arc is supplied by CNVII
§ Each fifth nerve communicates with both seventh nerves and therefore both eyes
close when each cornea is stimulated
§ Lightly touch the cornea with a wisp of cottonwool
§ Reflex blinking of both eyes is a normal response
8 [Vestibulocochlear] Nerve:
th
Two components:
§ Vestibular containing afferent fibres for balance
§ Cochlear with afferent fibres for hearing
Whisper Test
§ Ask the patient if they have any pain in the ears at the moment
§ Cover one ear with hand and whisper into the other ear
§ Test low pitch and high pitch in both ears by asking the patient to repeat after your
whisper:
o Low pitch: One hundred
o High pitch: Sixty-eight
§ Repeat on opposite side
§ Reporting:
o Normal hearing on one side
o Hearing deficit on the right /whisper test abnormal for both types of tone
Rinne’s Test
§ A vibrating tuning fork is placed on the
mastoid process behind the ear
§ Testing bone conduction:
o ‘Can you hear that? Tell me
when it stops’
o When it stops, place quickly
into air
§ When the sound is no longer heard it is
placed in line with the external meatus
§ Normally the sound is audible at the
external meatus
§ This is testing air conduction:
o ‘Can you hear that?’
o ‘Which was louder, the first or
the second?’
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Medicine
§ Air is louder – second should be louder

o Principle: Fluid conducts better than air, which conducts better than bone
§ Reporting:
o With nerve deafness, the note is audible at the external meatus, as air and
bone conduction are reduced equally, so that air conduction is better as is
normal
o This is termed Rinne-positive
§ Fluid or bone disease causing conductive deafness e.g. otitis media,
Paget’s disease (overgrowth of bone acts like fluid), tumour
o With conduction [middle ear] deafness no note is audible at the external
meatus
o This is termed Rinne-negative
§ Rinne’s test is only useful if there is asymmetrical hearing loss
Weber’s Test
§ A vibrating tuning fork is placed on the centre of
the forehead. Normally the sound is heard equally
in both ears
§ With sensorineural deafness the sound is
transmitted to the normal ear
§ With conduction deafness the sound is heard louder
in the abnormal ear
Audiometry
§ Patients with defective hearing should be referred for audiometry
§ This measures the degree of hearing loss at different sound frequencies
Examination of Vestibular Function

§ This cannot effectively be evaluated at the bedside
9 [Glossopharyngeal] and 10 [Vagus] Nerves
th th
Uvula Deviation
§ “Could you open your mouth and say ‘ah’
please?”
o Inspect the palate with a torch
o Note any displacement of the uvula
(away from the affected side)
Gag Reflex
§ Touch the back of the pharynx on each side
with a spatula
§ Ask the patient if the touch of the spatula is felt each time
§ Normally there is reflex contraction of the soft palate
§ Not routinely done
11 [Accessory] Nerve
th
Supplies motor fibres to the trapezius and SCM muscles

§ “Could you shrug your shoulders please? Don’t let me push them down”
o Palpate for muscle bulk of trapezius
o Assess muscle strength
§ “Could you turn your head to the left and push against my hand?”
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Medicine
o Place a hand at the patient jaw and assess bulk of the SCM on the side
opposite to the turned head
o Weakness on turning the head away from the affected side
12 [Hypoglossal] Nerve
th
Supplies motor innervation to the tongue

§ “Could you stick out your tongue please?”
o Inspect for:
§ Wasting
§ Fasciculation
§ Deviation: Towards the affected side in a unilateral LMNL
§ “Could you push your tongue against the inside of your cheek?”
o Push against the tongue with your hand
o Assess muscle strength
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Medicine
Common Cranial Nerve Pathologies

Cranial Nerve I: Olfactory Nerve
Differential Diagnosis for Anosmia:
§ Upper respiratory tract infection
§ Trauma to cribriform plate
§ Chronic sinusitis
§ ENT tumour
§ Abscess
§ Epilepsy
Cranial Nerves II, III & VI: Optic, Oculomotor and Abducens
Features of a CNII Palsy e.g. optic neuritis in MS
§ Abnormal acuity
§ Relative afferent pupillary defect (Eye is slower to receive the stimulus, thus slower
to constrict, looks like a relative dilatation)
Features of a CNIII lesion

§ Complete ptosis
§ Eye down and out
§ Fixed dilated pupil (not responsive to light and accommodation)Features of CNIV
lesion
§ Usually associated with a CNIII palsy
§ Double vision going down stairs
§ Ask patient to turn the eye in and then to look down
§ Superior oblique paralysis
Features of CNVI lesion

§ Failure of lateral movement
Features of Horner’s Syndrome

§ Cachexia
§ Partial ptosis
§ Anhidrosis
§ Meiosis (fixed dilated pupil)
§ Aetiology:
o Pancoast tumour (most common)
o C8-T1 trauma
o Carotid dissection
Lesions
§ Intact accommodation reflex + intact light reflex
o Syphilis
o Argyll Robertson pupil
o Adie pupil
§ Lesions of pupillary light reflex:

o If pupil constricts on the examined eye, but the pupil of the opposite eye does
not, then the lesion is most likely a CNIII palsy
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Medicine
Cranial Nerve V: Trigeminal Nerve

Causes of CNV Palsy
§ Aneurysm
§ Abscess
§ Tumour
§ ENT trauma/malignancy
§ Iatrogenic/surgery
§ Parotid lyme disease
§ Facial abnormalities
§ Cavernous sinus syndrome
Cause of Bilateral CNV Palsy:

§ Bilateral acoustic neuroma (associated with neurofibromatosis type II)
§ Classic facies: LMNLs of CNVII bilaterally post-resection of the acoustic
neuromas
§ Voice features
Lateral Medullary Syndrome

§ Ipsilateral pain and temperature of the face
§ Intact touch sensation
§ Caused by PICA – supplies midbrain and medulla, does not supply the pons, so the
pons (touch) stays intact
Acoustic Neuroma: Tumour at Cerebellopontine Angle (CPA)

§ Tends to affect cranial nerves VI, VII and VIII
§ Entire sensory loss of CNV
§ CNVI, VII and VIII leave at the same point – examine for those lesions
§ Scar at mastoid process
§ Corneal reflex
Cavernous Sinus Thrombosis

§ CNV lesion most commonly seen in orbital cellulitis
1
§ Seen in anti-phospholipid syndrome and post-partum sagittal sinus thrombosis
Cranial Nerve VII: Facial Nerve

UMNL e.g. on L side:
§ Most common cause of an UMNL is a stroke
§ Features:
o Drooping of the corner of the mouth
o Flattened nasolabial fold
o Sparing of the forehead on the left side
§ Causes of UMNL CNVII:
o Stroke
o Space-occupying lesion
o Pagets disease: Bony outgrowths
LMNL:
§ Most common cause of CNVII LMNL is a Bell’s palsy
§ Bells phenomenon: When the eyes are closed, try to open them and see if the pupils
are moving back to the back of the head
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Medicine
§ Most common complaint is dribbling/difficulties with swallowing

§ Treat with steroids
§ Causes of bilateral LMNL of CNVII:
o Sarcoidosis
o Guillain-Barre syndrome
o Lyme disease
o EBV
o Bilateral parotid disease e.g. mumps/chronic alcohol dependency
Cranial Nerve VIII: Vestibulocochlear Nerve

Pathologies:
1. Bilateral 9 nerve palsies: No sensory component either side = no gag reflex
th
2. Bilateral UMNL of 9 and 10 nerves: Exaggerated gag reflex because ???

th th
3. Pseudobulbar palsy (MND) – Associated with emotional lability

4. Bulbar palsy: Bilateral LMNL of CNIX and CNX (MND) – Associated with bulbar-
type speech which is nasal in character
Most common syndrome is MND with abnormalities of IX, X, XI and XII
Cranial Nerves IX & X: Glossopharyngeal and Vagus Nerves

§ CNIX: Sensory component
o Unilateral CNIX palsy: On affected side, nothing will happen as sensation
of the gag has not been transmitted
o The ninth nerve supplies taste from the posterior one-third of the tongue,
this is not routinely tested for
§ CNX: Motor component
o CNX palsy: Unilateral 10 nerve palsy
th
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CHAPTER 5
ENDOCRINOLOGY
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13. Clinical Examination of the Thyroid Gland
General Inspection
§ Mental status (agitation, anxiety, irritability)
§ Cachexia/weight gain
§ Devices e.g. ECG, cardiac telemetry
§ Hoarse voice
Close Inspection of the Hands and Wrist
Nails
§ Onycholysis (Plummer’s nails)
o Separation of the nail from the nail bed
§ Thyroid acropachy
o Similar to clubbing, specific to Graves
disease
Fine Resting Tremor

§ Caused by sympathetic overactivity
§ Ask the patient to hold their hands out, palms downwards
§ Place a sheet of paper on the back of the hands, inspect for tremor
Palms
§ Palmar erythema
o Rheumatoid arthritis
o Liver disease
o Pregnancy
§ Palpate for sweatiness/warmth
§ Pallor of palmar creases (hypothyroidism)
o Anaemia of chronic disease
o Vitamin B12 deficiency – associated with pernicious anaemia (associated
autoimmune disorder)
o Iron deficiency anaemia secondary to menorrhagia
§ Peripheral cyanosis (hypothyroidism)
o Reduced cardiac output
Wrist & Arms

§ Tinel’s Test
o Tap over flexor retinaculum
o Carpal tunnel is thickened in myxoedema, which may cause paraesthesia in
the distribution of the median nerve
§ Pulse
o Sinus tachycardia/bradycardia
o Atrial fibrillation (hyperthyroidism)
§ Blood pressure
o Hypertension is common in thyrotoxicosis/hypotension in hypothyroidism
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Medicine
Close Inspection of the Eyes and Face

Eyes
§ Conjunctival injection
§ Pallor – anaemia of chronic disease (hypothyroidism)
§ Xanthelasma (associated with hypercholesterolaemia, seen in hypothyroidism)
§ Chemosis
o Oedema of the conjunctivae
§ Corneal ulceration
o Due to inability to close eyelids
§ Lid retraction
§ Thyroid stare: ‘Wide-eyed’
§ Proptosis (Must look from above)

§ Exophthalmos (Must look from above)
o Protrusion of the eyeball out of the orbit in Graves disease
o Look from the front, both sides and above (ask px to look up)
o A result of increased tissue volume due to inflammation and accumulation
of glycosaminoglycans, stimulated by anti-TSH receptor antibodies, which
increase the osmotic pressure in the orbit, leading to fluid accumulation and
displacement of the eyeball forwards
o If exophthalmos is present, the eye will be visible anterior to the superior
orbital margin
o If not obvious look at the sclerae which in exophthalmos are not covered by
the lower eye lid
o Next look from behind over the patient’s forehead
§ Nystagmus/diplopia: H test
o For ophthalmoplegia/diplopia due to thyroid eye disease
§ Lid lag
o Ask patient to follow your finger as it descends from the upper to lower
aspect of the visual field
o Descent of the upper lid lags behind
descent of the eyeball
Face
§ Alopecia (hypothyroidism)
§ Dry, thickened skin (hypothyroidism)
§ Vitiligo (associated with Graves)
§ Loss of lateral 1/3 of eyebrow (hypothyroidism)
§ Hypercarotinaemia (decreased hepatic carotene
metabolism, seen in hypothyroidism)
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Medicine

Skin
§ Scars
o Thyroidectomy scar forms a ring around the base of the neck in the position
of a high necklace
§ Rash
o May occur in suppurative thyroiditis (rare)
§ Prominent veins
o Dilated veins over the upper part of the chest wall, often accompanied by
filling of the external jugular vein
o Suggestive of SVC obstruction secondary to retrosternal mass
Swellings
§ Inspect the front and sides of the neck and to identify localised or general swelling
of the gland; may be just visible in a thin, young person below the cricoid cartilage
§ The lateral lobes of the thyroid should have a volume no greater than the patient’s
terminal phalanges of the thumbs
§ Goitre is best observed with the neck slightly extended and observed best when it
moves on swallowing; this also allows the shape of the gland to be seen
§ Give the patient a cup of water: Ask to sip as you observe the neck swelling
carefully
§ ‘Take a sip of water and hold it in your mouth. Now swallow’
§ Inspect for:
o Movement of the gland with swallowing
o Base of the gland (implies the absence of retrosternal extension)
o Symmetry of the gland
§ Ask them to protrude tongue: Distinguish thyroglossal duct cyst
Jugular Venous Pressure

§ May be elevated in right heart failure (hypothyroidism)
Palpation of the Neck
Palpation of the Thyroid Gland: Posterior Approach
§ Ask the patients permission to feel the neck and then approach patient from behind,
slightly flex the head to relax the SCMs
§ With the right middle and index finger palpate for the cricoid cartilage
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Medicine
§ Below this palpate the isthmus of the thyroid gland

which lies over the trachea
§ Palpate the 2 lobes of the gland which extend
laterally behind the SCM muscle using the pulps of
the fingers
Comment upon:
§ Size: Feel for the lower border as its absence
suggests retrosternal extension
§ Surface: Smooth/nodular/diffusely enlarged
§ Consistency: Soft (normal)/firm (simple goitre)/hard (carcinoma)
§ Tenderness: Thyroiditis – subacute (or rarely, suppurative)
§ Movement: Ask the patient to swallow again whilst you palpate the gland. Thyroid
gland should move with swallowing (carcinoma may tether the gland)
§ Masses: If a single nodule is present describe its location, size, consistency,
tenderness and mobility. Determine if other nodules are present [multinodular
goitre]
Lymph Nodes
§ Approach from behind
§ Walk the fingers along the path of the
groups
§ Palpate laterally for lymph nodes, if you
find lymph node enlargement in the neck
check:
o Submental
o Submandibular
o Pre-auricular
o Posterior auricular
o Anterior cervical chain – Go all the
way to the midline, and that you are
palpating the entirety of the whole of the anterior triangle – down into the
sternal notch
o Posterior cervical chain – Posterior to SCM and anterior to traps, above the
level of the clavicle, use whole hand along the back of the neck
o Occipital – to the occipital protruberance (superficial portion of deep
cervical fascia inserts here, can still get lymph nodes here)
o Supraclavicular group
§ Enlarged lymph nodes near a goitre raise the suspicion of a carcinoma, particularly
if they are firm/hard
§ Description:
o Site
o Size
o Shape
o Fixed/mobile (Ask them to swallow and to protrude the tongue)
o Consistency
o Associated symptoms e.g. skin changes, pain
Percussion of the Neck
• Percuss superior portion of manubrium
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• Resonant → dull indicates possibility of a retrosternal goitre, but this is not a very
reliable sign
Auscultation of the Neck
• Auscultate over the thyroid for evidence of
increased vascularity which may occur in
hyperthyroidism
• Listen over each lobe for a bruit

• Ddx includes carotid bruit
Special Tests
1. Proximal Myopathy
§ Upper limbs:
o Ask the patient to raise the arms over the head
o Check for proximal muscle weakness
§ Lower limbs:
o Ask the patient to sit with arms crossed across the chest in a chair
o Stand from the chair without arms
o Check for proximal muscle weakness
2. Deep Tendon Reflexes

§ Upper limbs:
o Biceps (C5,6)
o Triceps (C7,8)
o Brachioradialis (C7,8)
§ Lower limbs:
o Knee jerk (L3,4)
o Ankle jerk (S1,S2)
3. Pembertons Sign
§ Ask the patient to raise both arms
over the head
§ Wait for up to 1 minute
§ Observe for:
o Facial congestion
[plethora]
o Facial cyanosis
o Respiratory distress
o Inspiratory stridor
o Dilated veins over the
upper chest and filling of
the external jugular vein
§ Ask the patient to take a deep breath through the mouth and listen for stridor
§ Positive Pembertons Sign: Indicate retrosternal extension and thoracic inlet
obstruction secondary to retrosternal mass
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Medicine
4. Examination of the Lower Limbs

§ Pretibial myxoedema
o Bilateral, firm and elevated
nodules/plaques caused by
mucopolysaccharide accumulation
in Graves disease
5. Auscultation of the Heart & Lungs

§ Auscultate heart sounds & examine for
systolic flow murmur
§ Pericardial/pleural effusion (hypothyroidism)
§ Perform a full cardiovascular examination + 12-lead ECG
§ Order TFTs and CXR
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Medicine
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14. Clinical Examination for Acromegaly
General Inspection
§ Alert and comfortable
§ General size
§ Position: Sitting at 45° angle
Examination of the Hands

§ Inspect:
o Size
§ Ask the patient ‘Have you ever worn a ring? Have
you had to have it cut away?’
o Shape
§ ‘Spade-shaped’ square appearance
o Hyperhidrosis
§ Palpate:
o Temperature
o Doughy/boggy (indicative of active disease)
o Skin thickness
§ Pinch the skin of the dorsal surface of the
hand and compare to your own
§ May be increased
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§ Examination of the median nerve:

o Inspect for wasting of the thenar eminence
o Test thumb abduction
o Test sensation over thenar eminence
o Tinel’s test
o Phalen’s test
Examination of the Arms
§ Blood pressure
§ Proximal myopathy
o Ask the patient to abduct the shoulders and push against them
Examination of the Face and Neck
Face
§ Large ears, nose or lips
§ Prominent supraorbital ridge
§ Prognathism
§ Macroglossia
§ Interdental separation
o Ask the patient ‘Can you show me your
gums?’
o Inspect for widened spacing between teeth
o Inspect for underbite
§ Eyes: Visual fields
o For bitemporal hemianopia
Neck
§ Goitre
§ Elevated JVP
Examination of the Lower Limbs
§ Inspect for spade-shaped feet
§ Examine for proximal myopathy:
o Ask px to cross their arms across their chest and stand up out of chair
§ Perform a full cardiovascular examination
§ Perform a cranial nerve examination
§ Order relevant investigations:
o 12-lead ECG
o Oral glucose tolerance test with growth hormone and IGF-1 measurement –
Failure of GH suppression confirms diagnosis
o Urinalysis (glycosuria) – in DM
o Blood sugars – in DM
o MRI pituitary with contrast – To diagnose pituitary adenoma
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15. Clinical Examination of the Breast
General Inspection
§ Colour (jaundice/pallor)
§ Nutritional status e.g. cachexia, high BMI
§ Devices e.g. central lines, drains (Jackson-Pratt drain),
IV antibiotics
§ Exposure and positioning: Sitting at edge of bed/lying
supine at 45°, exposed to the waist (with gown),
consider chaperone
§ Scars/radiation tattoos
o Breast surgery e.g.
WLE/reduction/augmentation
o Lower abdomen: DIEP/TRAM flap
o Back: LD scar
Close Inspection of the Breast
Outline
§ Asymmetry
§ Obvious masses
§ Ask the patient (whilst sitting upright):
o “Raise your arms over your head”
o “Place your hands onto your hips
and squeeze down”
o Observe for any obvious masses
Skin
§ Tethering
§ Dimpling
§ Eczema
§ Erythema
§ Peau d’orange
Nipples
§ Colour
§ Retraction
§ Bleeding
§ Discharge
§ Inversion
§ Ulceration
Palpation of the Breast
*Lie them at 45 degrees
§ Always palpate with the pulps of the fingers
§ Technique:
o Circular motion with light pressure
o Examine all four quadrants in a clock fashion, particularly around the nipple
alveolar
o Place the hand behind the head
o If large breast:
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§ Support with one hand

§ Examine with the other
§ Examination of axilla:
o Ask the patient to sit up in the bed
o Your right arm supports their right arm
o Examine against the chest wall:
§ Anterior: Against anterior axillary fold
§ Posterior: Posterior LD muscle
§ Apical: High up in the middle to palpate the apical nodes
Examination of the Lymph Nodes of the Head and Neck
Lymph Nodes
§ Ask the patent to sit forward, stand behind the
patient and explain that you are going to examine the
patient’s neck:
§ Carefully palpate for the following lymph nodes in
turn:
o SUBMENTAL node, which lies directly
under, the chin, then the
SUBMANDIBULAR nodes which are
below the angle of the jaw
o Posterior to the angle of the jaw feel for the
PAROTID node then palpate in front of the tragus for the
PREAURICULAR node
o Now palpate behind the ear for the POSTAURICULAR node, then to the
posterior aspect of the head for the OCCIPITAL node
o Now ask the patient to relax their shoulders and palpate down the anterior
border of the sternocleidomastoid muscle for the ANTERIOR CERVICAL
CHAIN of nodes including the TONSILLAR (JUGULODIGASTRIC) node
o At the inferior end ask the patient to slightly shrug their shoulders and feel
for the SUPRACLAVICULAR nodes
o Now palpate for the POSTERIOR CERVICAL CHAIN of nodes at the
posterior border of the sternocleidomastoid muscle and the posterior triangle
of the neck
§ Perform triple assessment for any breast lump
o Clinical: Full clinical history and examination
o Radiological: Mammogram +/- ultrasound breast
o Histological: Core needle biopsy for definitive diagnosis
§ Perform a full systematic examination to look for evidence of metastatic disease
o Do not mention this within earshot of patient in case they have not been
counselled about the possible cancer diagnosis
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16. Clinical Examination of the Diabetic Patient
General Inspection
§ Breathing e.g. hyperventilation in metabolic acidosis
§ Hydration status e.g. dry mouth/loss of skin turgor (dehydration due to osmotic
diuresis caused by glucose load)
§ BMI e.g. obesity/underweight due to weight loss
§ Stigmata of endocrine disease e.g. Cushingoid facies,
acromegaly, pigmentation in haemochromatosis
§ Devices* e.g. insulin pens, glucometers, IV lines, diabetic
diet sign
§ Exposure and positioning: Supine at 45°, exposed for
lower limb examination
*Inspect the shoes for pattern of wear and alterations
§ Fingerprick signs
§ Signs of carpal tunnel syndrome (median nerve entrapment)
o Thenar wasting
o Tinel’s sign
§ Tap over median nerve at carpal tunnel
§ Px gets sensation of parasthesia
o Phelan’s sign
§ Turn hands upside down and press backs of hands together
§ Px gets pain after about 30 secs
§ Look for ulnar nerve entrapment signs
o Hypothenar wasting
Skin
§ Signs of arterial insufficiency
o Pallor
o Hair loss
o Dry skin
o Fissures/skin breaks
§ Signs of venous disease

o Oedema
o Venous eczema
o Lipodermatosclerosis
§ Signs of infection
o Erythema
o Swelling
o Cellulitis
o Gangrene
o Necrobiosis lipoidica
diabeticorum: Red/brown/ yellow, raised and often ulcerated patches
usually on shins [rare]
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§ Signs of neuropathy
o Charcot joint (collapse of the
medial longitudinal arch due to
loss of protective pain sensation)
o Pes planus
o Pes cavus
o Muscle wasting e.g. wasting of
the quadriceps due to femoral nerve mononeuropathy
o Lipoatrophy of the thighs
Sole of the Foot

§ Fungal nail infections
§ Onychogryphosis
§ Rubor/corns/callouses at pressure points
§ Bony prominence e.g. Charcot joint
§ Neuropathic ulcers
Between the Toes

§ Dry skin
§ Fissures
§ Ulcers
Examination of the Diabetic Ulcer
§ Site: Pressure areas/sole of foot
§ Depth: Deep
§ Edges: Punched-out
§ Base: Sloughy & bloody
§ Colour: Red
§ Associated features:
o Painless
o Signs of sensory neuropathy e.g. Charcot joint
o Signs of venous/arterial disease
Palpation
Temperature
§ Use back of each hand
§ Compare sides
Capillary refill time
§ Should be <2 seconds
Peripheral pulses
§ Dorsalis Pedis: Draw a line midway between
the medial and lateral malleoli, and a
perpendicular line to the 1 dorsal webspace.
st
The pulse of the DP artery is in the proximal

1/3, lateral to the tendon of extensor hallucis
longus
§ Posterior Tibialis: Midway between the heel
and the medial malleolus
§ Popliteal: Within the popliteal fossa; ask the
patient to flex the knee
§ Femoral: 1.5cm inferior and medial to the
mid-inguinal point, which is midway between the ASIS and the pubic symphysis
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Sensory Neurological Examination of the Lower Limb

Vibration
§ Carried within the dorsal columns
§ The base of the vibrating tuning fork is then placed on the dorsum of the terminal
phalanx
(1 MTP joint, lateral malleolus, upper part of tibia, iliac crest, costal margin)
st
Proprioception
§ Grasp the distal phalanx from the sides and move it up and down to demonstrate
these positions to the patient
§ Then ask the patient to close the eyes while these manoeuvres are repeated and ask
them to tell you the movement i.e. up or down (max 5mm in the feet, in the finger
1mm – this is how sensitive our ability to test proprioception should be)
If there is an abnormality, proceed to test the ankles and knees similarly
Sensation
Light Touch
§ Initially touch (do not drag as it moves
hair fibres) the anterior chest wall
(normal area); this is to demonstrate to
the patient how it feels
§ Ask the patient to close their eyes and
begin proximally on the upper leg and
test each dermatome (the area of skin
supplied by a vertebral spinal segment)
comparing right with left
§ Ask patient to say ‘yes’ every time they
feel something
§ To demonstrate whether it is
dermatomal or not in distribution, track
with cotton wool (peripheral
neuropathy is non-dermatomal in
origin, so they will have some loss of
sensation in one area and preserved
sensation in another within the same
dermatomal distribution)
Sharp Touch
§ Using a neurotip, touch the patient
anterior chest wall (normal area) to demonstrate to the patient how it feels sharp
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§ Ask the patient to close their eyes and begin proximally on the upper leg and test
each dermatome comparing right with left
§ Map out the extent of any area of dullness
§ Always do this by going from the area of dullness to the area of normal sensation
Dermatomes of the Lower Limb:

§ L2: Antero-medial mid-thigh
§ L3: Above the knee
§ L4: Medial malleolus
§ L5: Dorsal 1 webspace of the foot
st
§ S1: Lateral heel/small toe

Monofilament Testing
§ Use 10-g monofilament to test for
sensation on the sole of the foot
§ “Close your eyes please, and say ‘yes’
every time you feel this touch your foot”
§ Use monofilament extended fully out,
with enough force to make it bend
§ Touch the foot in multiple places
§ Perform a full neurovascular examination
§ Perform a full cardiovascular examination including erect and supine BP
o HR >100BPM: Sign of autonomic neuropathy
o Auscultation of the carotids for bruit
o Postural hypotension of >20/10 mmHg is a sign of autonomic neuropathy, or
severe dehydration, in an acutely unwell patient
§ Perform a gastrointestinal examination for signs of hepatomegaly (fatty liver or
haemochromatosis) and signs of fat atrophy/haematoma (if injecting insulin)
§ Perform a respiratory examination
o Signs of infection
§ Annual review
o All patients with diabetes should be screened annually for DPN by checking
any of the five tests (use of a 10-g monofilament, vibration testing using a
128-Hz tuning fork, tests of pinprick sensation, ankle reflex assessment, and
testing vibration perception threshold with a biothesiometer)
o Signs of diabetic neuropathy:
§ Loss of light touch
§ Loss of vibration
§ Consider pin prick and ankle reflexes
o Examine the eyes for signs of diabetic retinopathy (see below)
o Bedside: Glucose fingerprick, ABPI, Doppler US +/- ABG, and urinalysis
for:
§ Microalbuminuria* (albumin/creatinine ratio) for assessment of
nephropathy
§ Protein, glucose and ketones
• if present, urine culture and sensitivity
o Bloods: Blood glucose, HbA1C, U&Es, OGTT
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§ Medication review
§ Education and counselling of patient
*Exercise within 24hr, infection, fever, CHF, marked hyperglycaemia, and marked
hypertension may elevate urinary albumin excretion over baseline values
Annual Review of Diabetic Patient: Examination of the Eyes

§ Check visual acuity which could be impaired in a diabetic due to retinopathy,
temporarily disturbed because of changes in the shape of the lens associated with
hyperglycaemia or permanently, due to cataracts
§ Check 3 , 4 and 6 cranial nerves
rd th th
o Diabetic CNIII palsy from ischaemia, usually spares the pupil

o CNIII palsy from a posterior cerebral artery aneurysm doesn’t spare the pupil;
disease is within neurons themselves
Fundoscopy:
§ “I would inspect the eyes for signs of retinopathy”
§ Stages of retinopathy
§ Use the ophthalmoscope first at arm’s length, to check for
o Rubeosis iridis (new blood vessel
formation in the iris which can lead to
glaucoma)
o Cataracts (due to sorbitol deposition
in the lens) – retina will be red and
cataract black
§ Come close to the eye, find optic disc and
look in all four retinal quadrants, following four
retinal arteries
§ Examine for:
o Non proliferative changes: (caused directly
by ischaemia)
§ Microaneurysms: due to vessel wall
damage
§ Dot haemorrhages, they originate in
the inner retinal layer.
§ Blot haemorrhages (Occur more superficially in the nerve fibre layer)
§ Soft exudates (cotton wool spots)- fluffy appearance
§ Hard exudates (Due to lipid and protein deposition) - have straight
edges
§ Venous beading
o Proliferative changes:
§ Changes in the blood
vessels in response to retinal
ischemia and are associated
with new vessel formation
(neovascularisation) which
bleed easily (vitreous
haemorrhage), scar formation and eventually retinal detachment
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CHAPTER 6
MUSCULOSKELETAL MEDICINE
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17. Surgical Examination of the Hands
General Inspection
§ Asymmetry of the upper limb/obvious dysmorphic features e.g. amputations
§ Obvious signs of trauma of the upper limb
§ Devices e.g. splints, casts, medications
§ Exposure: To the elbows
§ Scars
o Carpal tunnel release (palm/wrist)
o Brunner’s scar (Dupuytren’s contracture release)
o Check elbows
§ Colour e.g. pallor
§ Trauma/deformities
§ Dupuytren contracture
§ Abnormal posturing
o Wrist drop: Radial nerve palsy
o Partial claw hand (clawing of little and ring finger): Weak medial lumbricals
with unaffected lateral lumbricals
§ Median nerve
o Wasting of thenar eminence: ‘Begging’ position, hands together with palms
up
o Compare both sides
o Carpal tunnel decompression scar (palm/wrist)
§ Ulnar nerve:
o Wasting of hypothenar eminence: ‘Begging’ position, hands together
o Dorsal surface: Wasting of the dorsal interossei
o Partial claw hand: Due to weak medial lumbricals (lateral lumbricals are
unaffected as they receive innervation from median nerve)
o Elbows: Scars/evidence of trauma or deformity
§ Radial nerve:
o Wrist drop
Palpation
§ Temperature
§ Wasting of the thenar/hypothenar eminences
o Thickening of the palmar fascia
o Begin proximally at the wrist and move distally
o Palpate at the base of the fingers (particularly the ring and little fingers) for
nodules/thickened cords
Power
§ Median nerve:
o Thumb abduction (palms upwards, point the thumb towards the sky)
§ “Don’t let me push it down”
o Thumb opposition
§ “Hold your thumb to your little finger. Don’t let me break the ring
between the two”
§ Ulnar nerve:
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o Finger abduction/adduction
§ “Place your fingers together. Now spread your fingers”
• “Push your little finger against mine”
§ Radial nerve:
o “Make a fist with your hand. Push against mine”
o “Keep your fingers together. Push up against my hand”
Sensation
Median
Ulnar
Radial
Musculocutaneous
Medial antebrachial cutaneous
Dorsal Surface of the Hand Palmar Surface of the Hand
Median Nerve
§ Palmar side: Sensation to radial 3½ digits on palmar side
§ Dorsal side: Sensation to fingertips of 2 , 3 and ulnar half of 4 digits
nd rd th
§ Test: Sensation over thenar eminence (palmar side)
Ulnar Nerve
§ Palmar side: Sensation to ulnar 1½ digits
§ Dorsal side: Sensation to ulnar 1½ digits
§ Test: Sensation over hypothenar eminence (palmar side)
Radial Nerve
§ Palmar side: Sensation over underside of thenar eminence
§ Dorsal side: Sensation over dorsum of radial 3 ½ digits (except fingertips of 2 , 3
nd rd
and ulnar side of 4 )

th
§ Test: Sensation over 1 interosseous space on dorsal side

st
Special Tests
1. Froment’s Sign
§ Test for adductor pollicis
§ Nerve: Deep branch of ulnar nerve
§ Ask patient to pinch a piece of paper between a straight
thumb and index finger
§ Instruct to grip paper as you pull it away
§ Positive test: Flexion of the DIP joint of thumb (see
picture)
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2. Tinel’s Test
§ Repeatedly percuss over the carpal tunnel (ventral wrist)
§ Positive test: Parasthesia in median nerve distribution
§ Aetiology: Carpal tunnel syndrome
3. Phalen’s Test
§ Wrist held in flexion for 30-60 seconds
4. Derken’s Test
§ Compress the carpal tunnels for 30-60 seconds
§ More sensitive and specific sign of carpal tunnel syndrome
5. Allen’s Test
§ Ask patient to open and close the hand as quickly as possible, then squeezing the
hand tightly shut
§ Occlude the radial and ulnar arteries with your
thumb, and hold for several seconds
§ Ask the patient to open the palm and observe for
pallor of the palm
§ Release the radial artery, and observe for return
of colour to the palm (indicates patency of the
blood supply)
§ Repeat with ulnar artery
§ Perform a full upper limb neurological assessment
§ Investigations: XR hand, nerve conduction studies
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18. MSK Examination of the Hip
General Inspection
§ Alert, comfortable and well
§ Asymmetry of the lower limbs
§ Obvious dysmorphic features
§ Obvious leg length discrepancies
§ Devices e.g. mobility aids/crutches, splints, medications, drains in situ
§ Exposure and positioning: Lower limb exposed, patient sitting/supine at 45˚
Inspection of the Hip
§ Ask the patient to stand
§ Ask patient to turn to the side, then turn with their back to you
Inspection
§ Scars
§ Symmetry
§ Pelvic tilt
§ Muscle wasting e.g. gluteal wasting
§ Deformities e.g. fixed flexion deformity
§ Leg length discrepancy
§ Ask patient to walk to the other end of the room, turn back quickly and come back
§ Inspect for:
o Normal speed and symmetry of gait
o Heel strike and toe off
o Antalgic gait
Trendelenberg Test
§ Standing on normal leg only, gluteus medius on supported leg contracts and elevates
the pelvis on the unsupported side
§ This elevation indicates that the gluteus medius on the supported side is functioning
properly (negative Trendelenburg sign)
§ If the pelvis on the unsupported side drops,
the gluteus medius on the stance side is
either weak or non-functioning (positive
Trendelenburg sign)
§ Causes of positive Trendelenberg test:
o Abductor weakness/nerve damage
(superior gluteal nerve supplies
gluteus medius and minimus)
o Subluxation/dislocation of hip
o Shortening of the femur
Palpation of the Hip
§ Skin: Temperature (with back of hand)
§ Soft tissue: Swelling, tenderness
§ Bone: Greater trochanteric tenderness, ASIS, iliac crests, pubic rami (trochanteric
bursitis)
§ Peripheral pulses
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§ Distal sensation
§ Leg length discrepancy:
§ True leg length: Measure ASIS to

medial malleolus
§ Apparent leg length: Measure
umbilicus to medial malleolus
§ If discrepancy occurs, check to
determine if the femur or the tibia is the
longer bone
Movement of the Hip *ALWAYS STABILISE THE JOINT

Active Flexion
§ Place hand under small of back
§ Ask patient to bring the knee up to the chest (should be 120°)
§ Repeat on contralateral limb
Active Abduction and Adduction
§ Ask patient to bring the hip out to the side
§ Then cross across the contralateral side
Active Rotation (Good measurement of general hip function)
§ Draw a circle with the foot
Passive Flexion, External and Internal Rotation
§ Passive flexion:
Flex the patient’s knee
towards the chest
(passive flexion)
§ Passive
internal rotation:
Bend the knee to 90°,
support at the joint
and internally rotate
(bring out away from
the body) – normal
angle is 40°
§ Passive external rotation: Bend the knee to 90°, support at the joint and externally
rotate (bring towards the body) – normal angle is 30°
Passive Abduction and Adduction
§ Stabilise the joint on opposite side at the ASIS
§ Passive abduction: (Normal 45°)
§ Passive adduction: (Normal 30°)
Passive Extension
§ Ask patient to lie prone
§ Stabilise the small of the back
§ Extend the hip (10-20°)
§ Repeat on opposite side
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Special Tests of the Hip

1. Modified Thomas Test
§ Turn the patient back over to supine

§ In supine, flex the unaffected hip
§ If the affected hip rises from the plinth,
this indicates a loss of extension in the
hip i.e. presence of a fixed flexion
deformity (positive Thomas test)
§ No elevation of the contralateral leg =
negative Thomas test
§ Examine distal pulses and lower limb neurological exam (neurovascular integrity)
o Dorsalis pedis pulse, posterior tibial pulse + CRT
o Sensation on dorsum of foot and sole of foot
§ Offer to examine joint above and below (knee and spine)
§ Request imaging [XRs (AP and lateral view) of hip , MRI hip] +/- joint aspiration
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19. MSK Examination of the Knee
General Inspection
§ Alert, comfortable and well
§ Asymmetry of the lower limbs
§ Obvious dysmorphic features
§ Devices e.g. mobility aids/crutches, splints, medications, drains in situ
§ Exposure and positioning: Lower limb exposed, patient sitting/supine at 45˚
Close Inspection of the Knee*
*Ask patient to stand if able, comment if they can weight-bear
Inspection of Anterior Joint

§ Scars
§ Asymmetry of the joints
o Valgus deformity: Knock-kneed
e.g. OA, RA
o Varus deformity: Bow-legged e.g.
rickets, OA
§ Erythema
§ Swelling/loss of patellar borders
§ Haematoma/ecchymoses
§ Signs of trauma
Inspection of Lateral Joint

§ Wasting of the quadriceps/hamstring muscles
§ Fixed flexion deformity
§ Scars
Inspection of Posterior Joint

§ Scars
§ Swellings e.g. popliteal aneurysm, Baker’s cyst, DVT
§ Ask patient to walk to the other end of the room, turn back quickly and come back
§ Inspect for:
o Normal speed and symmetry of gait
o Heel strike and toe off
o Antalgic gait
Palpation of the Knee
§ Temperature
o With back of hand
o Check superior to patella and along joint lines
o Compare like with like
§ Muscle bulk
o Measure circumference of the thigh 10cm above the patella, compare sides
§ With knee flexed to 90°
o Medial and lateral joint lines
o Patellar tendon insertion
§ With leg straight
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o Quadriceps tendon
o Patellar borders
o Popliteal fossa
§ Patellar tap
o Test for large joint effusion
o With leg straight, push the suprapatellar bursa towards the patella
o Tap the patella
o Positive test: ‘Tap’ of patella as it sinks to tap the femur and bounces back to
rest due to excessive fluid accumulation in the joint
§ Sweep test
o Test for small joint effusion
o With the leg straight, run the hand up the medial side of the knee 2-3 times
o Immediately run the hand down the lateral side of the knee
o Watch for ‘bulge’ of fluid in medial compartment
Movement of the Knee
Active Movement
§ Flexion: “Bring your heel to your bum”
§ Extension: “Straighten your leg back out”
§ Hyperextension: “Push the back of the knee into the bed”
§ Straight leg raise: “Keep your leg straight and raise it up from the bed” (Tests for the
integrity of the quadriceps extensor mechanism)
Passive Movement
§ “Tell me if I cause you any discomfort”
§ Keep a hand on the knee joint whilst examining for crepitus
§ Movements:
o Flexion
o Extension
Special Tests of the Knee
1. Anterior and Posterior Drawer Tests
§ For anterior and posterior cruciate
ligament test
§ Knee flexed 90˚ (check
hamstrings relaxed)
§ Anterior drawer test: Pull the tibia
forward from the femur to assess
the integrity of the anterior
cruciate ligament
o Positive anterior drawer
test: Excessive laxity
compared to the opposite
side indicates a positive
test
§ Posterior drawer test: Push the
tibia backwards relative to the
femur to assess the integrity of the posterior cruciate ligament
o Positive posterior drawer test: Excessive laxity compared to opposite side
indicates a positive test
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2. Lachmanns Test
§ A more sensitive test for the integrity of

the ACL (along with the anterior drawer
test)
§ Knee held in 15˚ flexion and in lateral
rotation (which relaxes the iliotibial
band)
§ When the examiner chooses to examine
the right knee, they should hold the
inner aspect of the upper part of the right
lower leg with their right hand and the
outer aspect of the lower part of the
thigh with their left hand
§ On anteriorly gliding the tibia, the examiner will feel a firm end-feel if the Anterior
Cruciate ligament is intact
§ If the end-feel is loose and not firm, this is a positive test
§ Always compare both knees
3. Medial and Lateral Collateral Ligament Test
§ Patient supine
§ Knee in 30 ˚ flexion
§ Examiner applies alternate valgus and
varus forces against the joint line
§ Valgus force tests the MCL
§ Varus force tests the LCL
§ Positive test: Excessive laxity and/or
pain compared to opposite side
4. McMurrays Test
§ Patient supine
§ Examiner externally rotates the tibia on the femur and
applies valgus (abduction) force to the joint (stresses the
MCL), whilst keeping a hand across the joint line and
extending the leg
§ Examiner then flexes the knee again
§ Examiner internally rotates the tibia on the femur and
applies a varus (adduction) force to the knee joint
(stresses the LCL) whilst keeping a hand across the joint
line and extending the leg
5. Patellar Apprehension Test

§ Patient lies supine on the table with knee in 30 ˚ flexion
and quadriceps relaxed
§ The examiner carefully glides the patella laterally
observing for the apprehension sign
§ A positive test is the presence of this reaction from the
patient
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§ Perform a musculoskeletal examination of the joint above and below (hip and ankle)
§ Assess the neurovascular integrity of the lower limb
o Sensation on dorsal/sole of the foot
o Peripheral pulses + capillary refill time
o Imaging: XR knee (AP and lateral, to include joint above and below), MRI
knee, joint aspiration, septic screen
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20. MSK Examination of the Shoulder
General Inspection
§ Posturing
§ Asymmetry of the upper limb
§ BMI, signs of frailty
§ Signs of trauma
§ Devices e.g. mobility aids, implantable cardiac devices, oxygen tanks, medications
§ Exposure and positioning: To the waist, seated/supine at 45°
Close Inspection of the Shoulder
Ask the patient to stand if possible
§ Scars e.g. previous arthroscopy, joint
replacement
§ Asymmetry of the joint
§ Muscle wasting e.g. deltoid due to long-
standing tear
§ Bony misalignment/deformities e.g.
dislocation, clavicular fracture
Ask the patient to push against a wall

§ Inspect for winging of the scapula e.g.
damage to long thoracic nerve of Bell
(serratus anterior)
Palpation of the Shoulder
§ Palpate for temperature using the back of the hand, comparing sides
§ “Tell me if I cause you any discomfort”
o Begin at the SC joint
o Palpate along clavicle and AC joint
o Palpate anterior joint line, acromion, long head of biceps and posterior joint
line
o Palpate borders and spine of scapula
§ Assess for:
o Temperature of the skin
o Swelling of soft tissues
o Swelling of muscles
o Normal bony alignment
o Bicipital tendonitis: Along the biceps groove
o Supraspinatous tendonitis: Under the surface of the acromion; place a finger
over the head of the tendon when shoulder is in extension
o Rotator cuff pathology: Tenderness over greater tuberosity
Movement of the Shoulder
Active Movement
§ Flexion (180°): “Bring your arms up over your head”
§ Extension (50-60°): “Bring your arms straight back behind you”
§ Abduction (180°): “Bring your arms straight up from your sides”
o Tests glenohumeral abduction to 90°
o Possible to reach 180° in active movement as scapular involvement
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§ Adduction (180°): “Bring your arms straight back down to your sides”
§ Internal rotation (90°): “Bring your thumb behind your back to touch your shoulder
blade”
o Measure by level of vertebra reached
o Painful if rotator cuff pathology present
§ External rotation (60°): “Pin your elbows to your sides and turn your arms outwards”
Passive Movement
Be sure to stabilise the joint as you palpate for crepitus in passive movement
§ Slow abduction arc (to detect painful arc in impingement syndrome)
Special Tests of the Shoulder
1. Gerber Lift-Off Test: Subscapularis
§ Ask the patient to internally rotate the shoulder, with
dorsum of the hand against the mid-lumbar spine
§ “Push against my hand”
§ Positive test: Pain/weakness indicates subscapularis
pathology
2. Jobe’s Test: Supraspinatus

§ ‘Gladiator’ position
§ Ask the patient to hold the arms straight out from the
sides, turning the thumb to the floor
§ “Keep your arm up and don’t let me push it down”
§ Force shoulder adduction against resistance
§ Positive test: Pain/difficulty indicates supraspinatus
pathology
3. Resisted External Rotation: Teres Minor and Infraspinatus

§ Ask the patient to externally rotate the shoulder (arms adducted, elbows flexed to
90°)
§ “Push against my hands”
§ Positive test: Pain/difficulty indicates teres minor/infraspinatus pathology
4. Hawkins Test: Impingement Syndrome

§ Flex the shoulder to 90°, flex the elbow to 90° and
internally rotate the shoulder
§ Stabilise px elbow with one hand
§ Force further internal rotation with other hand
§ Positive test: Pain/difficulty indicates impingement
syndrome
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5. Scarf Test: Osteoarthritis

§ Bring the right hand to the left shoulder
§ Push against the forearm whilst stabilising the joint
§ Positive test: AC joint pathology
6. Apley Scratch Test

§ General assessment of shoulder movements
§ One arm is externally rotated and brought behind the
head, whilst the other is internally rotated
§ Good indicator of overall joint range of movement
7.Shoulder Apprehension Test: Instability/Dislocation

§ Ask the patient to lie supine
§ Abduct the shoulder to 90, flex the elbow to 90, and externally
rotate the shoulder
§ Stabilise px elbow with one hand
§ Force further external rotation with other hand
§ Positive test: ‘Apprehensive’ reaction to this (may occur if
history of previous dislocation)
Functional Assessment
§ “Place both your hands behind your head” (washing hair, dressing)
§ “Place both your hands to your mouth” (eating, drinking)
§ “Bring both your hands to your bum” (personal hygiene)
Neurovascular Integrity
§ Sensation
o Axillary nerve: Regimental badge area
o Median: Lateral aspect of index finger
o Ulnar: Lateral aspect of little finger
o Radian: Dorsal 1 interosseous space
st
§ Vascular
o Radial pulse
§ Perform a full neurovascular examination of the upper limb
§ Examine the joint above and below (cervical spine and elbow)
§ Perform relevant investigations e.g. XR shoulder (modified axillary and AP
view)/MRI shoulder, joint aspiration
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21. MSK Examination of the Spine
General Inspection
§ Posturing
§ Abnormal curvatures
§ Devices e.g. mobility aids, implantable cardiac devices, oxygen tanks, medications
§ Exposure and positioning: To the waist, seated/supine at 45°
Close Inspection of the Spine
§ Symmetry
§ Skin: Erythema, rash, scars, trauma
§ Soft tissue: Swelling, bruising, muscle wasting, naevus,
protuberant abdomen
§ Bone: Abnormal curvatures, deformities or alignments
o Scoliosis: Loss of lateral curvature of the spine
o Kyphosis: Excessive convex curvature of the
thoracic spine
o Lordosis: Excessive concave curvature of
the lumbar spine
o Fixed thoracic kyphosis, loss of lumbar
lordosis, extension of the cervical spine:
Ankylosing spondylitis
Palpation of the Spine

§ Begin from the base of the occiput down the midline of spinous processes to 5 th
lumbar vertebra
§ Iliac crests are level with 4 /5 lumbar vertebrae
th th
§ Palpate for sacroiliitis

§ Assess for:
o Temperature of the skin
o Swelling of soft tissues
o Swelling of paraspinal muscles
o Normal bony alignment
Movement of the Spine
Active movement only
§ Flexion of the cervical
spine: Ask the patient to
bend the chin to the chest
§ Extension of the cervical
spine: Ask the patient to
bend the head back
§ Rotation of the cervical spine: Ask the patient to turn the head to both sides as far
as possible
§ Lateral flexion of the cervical spine: Ask the patient to touch the right ear to the
right shoulder; repeat on other side
§ Flexion of the spine: Ask the patient to bend forward and touch the toes
§ Extension of the spine: Ask the patient to lean backwards as far as they can
without falling
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§ Rotation of the thoracic spine: Ask the patient to rotate at the hip from side to
side
§ Lateral extension: Ask the patient to slide one hand down the side towards the
ankle, repeat on other side
Special Tests of the Spine
Schober’s Test
§ Assesses movement in the lower lumbar spine
§ The examiner places a finger (or mark) on the
patients skin centrally over the 5 lumbar
th
vertebra
§ Two other marks are made, one 10cm above
this point and one 5cm below this point
§ There are therefore two marks, 15cm apart
§ The patient is asked to bend forwards to touch
the floor
§ If the two points do not separate by more than 5cm (over 20cm in total) this is a
positive Schobers test
§ This may indicate restriction of lumbar spine flexion e.g. can be associated with
ankylosing spondylitis
Straight Leg Raise
§ Patient lies supine with knees

extended
§ Examiner lifts each of the
patient’s outstretched legs off the
bed to assess if pain is reproduced
in the distribution of the sciatic
nerve (L5/S1 nerve root
compression)
§ Causes of a positive SLR:
1. Radiculopathy
2. Impingement of sciatic nerve
Occiput-to-Wall Test
§ The patient is asked to stand against a flat wall
§ The examiner tries to slide their hand between the
lumbar spine and the wall
§ If there is excessive lumbar lordosis, the entire
hand or arm may be able to fit in this space
§ Positive test may indicated ankylosing
spondylitis/thoracic vertebral fracture
Femoral Stretch Test

§ Ask the patient to lie on their front
§ “Let me know if I cause you any pain”
§ Hold the thigh and ankle, keep the leg straight and
extend the hip
§ Positive test: Back pain radiating down the anterior
leg (L4 nerve root compression)
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§ Perform a cardiovascular and respiratory examination for extra-articular features of
ankylosing spondylitis
o Apical fibrosis
o Aortic regurgitation
§ Perform a full musculoskeletal assessment and examine for features of ankylosing
spondylitis e.g. anterior uveitis, Achilles tendonitis
§ Perform a full neurological examination of the lower limbs, including a DRE if
indicated
o XR/MRI spine
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22. Clinical Examination for Rheumatoid Arthritis

General Inspection
§ Obvious asymmetry or posturing
§ Stigmata of rheumatoid disease e.g. malar rash, anterior uveitis, cushingoid facies
due to steroid use
§ Devices e.g. mobility aids, medications, IV fluids
§ Exposure and positioning: To the elbows, hands on a pillow for comfort
Examination of the Hands
Close Inspection of the Hands and Elbows
Dorsal Surface of the Hands
Skin:
§
o Scars
o Erythema
§ Soft tissues:
o Swelling
o Heberden’s node: At the DIP
o Bouchard’s node: At the PIP
o Calcinosis/thickening of the skin e.g.
CREST syndrome
o Flexion deformity of fingers e.g.
Dupuytren’s, partial claw hand,
scleroderma, OA – “Can you make a
praying sign?”
§ Bony deformities:
o Bilateral symmetrical polyarthropathy with sparing of the DIPs: RA pattern
o Boutonniere’s deformity: Flexion of the PIP with hyperextension of the DIP
o Swan neck deformity: Hyperextension of the PIP with flexion of the DIP
o Z-thumb
o Ulnar deviation of the wrist
o Radial deviation of the MCPs
o Subluxation
o Prominent ulnar styloid
o Swelling of the wrist/erythema
Nails
§ Vasculitic nail changes e.g. pitting,
onycholysis, ridging
§ Nailfold infarcts e.g. SLE
§ Splinter haemorrhages e.g. vasculitis
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§ Clubbing e.g. other underlying pathology

§ Leuconychia
§ Koilonychia
Palmar Surface of the Hands

§ Scars e.g. CT release, Brunner’s scar (Dupuytren’s)
§ Pallor of palmar creases e.g. anaemia of chronic
disease
§ Wasting of thenar/hypothenar eminence e.g. CT syndrome
§ Palmar erythema e.g. RA, chronic liver disease, hyperthyroidism, pregnancy
§ Synovitis:
o “Can you make a fist with your hands?” – look for loss of valleys between
the MCP heads due to synovitis
Elbows
§ Inspection:
o Rash
o Subcutaneous nodules (RA, gout)
o Enlarged bursa (fluid)
o Colour of nodules (yellow: gout)
o Swelling (joint effusion)
o Psoriasis (psoriatic arthritis)
§ Palpation:
o Warmth
o Enlarged bursa
o Nodules: Hard (RA) or firm (gout)
o Lateral epicondyle: Tenderness =
tennis elbow
o Medial epicondyle: Tenderness = golfer’s elbow
§ Movement:
o Flexion: Normal 150°
Ears, Neck and Scalp

§ Psoriatic plaques
§ Gouty tophi on ears
Palpation of the Hands
Temperature
§ Use the back of the hand
§ Compare like with like
o Dorsal MCPs
o Dorsal surface of wrist
Palm
o Move from proximal to distal
o Palpate for thickening of palmar fascia/cords/nodules
o Tends to affect the 4 and 5 fingers most commonly
th th
Tenderness and Swelling

§ Squeeze across each joint, feeling for swelling/tenderness
o Wrists
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o MCPs
o Thumb interphalangeal joints
o Each interphalangeal joint of remaining digits, compare like with like
§ Character of the swelling: Synovial inflammation feels boggy, effusion is fluctuant
Movement of the Hands
Active Movement
§ Finger flexion: “Make a fist”
§ Finger extension: “Straighten your fingers”
§ Finger abduction: “Spread your fingers out”
§ Finger adduction: “Close them together”
§ Wrist flexion: “Make a fist and bend the wrists down”
§ Wrist extension: “Make a fist and pull the wrists up”
§ Radial deviation of the wrist: “Make a fist and turn the wrists towards you”
§ Ulnar deviation of the wrist: “Make a fist and turn the wrists away from you”
§ Pronation of the forearm: “With your palm facing upwards, turn the palm downwards
to face the floor”
§ Supination of the forearm: “With your palm facing downwards, turn the palm
upwards to face the sky”
§ Trigger finger: “Can you make a fist with your hands? Now quickly straighten your
fingers”
o +ve test: DIP remains in flexion due to fixed flexion deformity
Passive Movement
Move all the joints gently in their normal plane of movement, starting proximally at the wrist
and moving distally
§ “Tell me if I cause you any pain”
§ Stabilise each joint as you repeat movements above
§ Palpate for crepitus and warmth, watch px face for signs of pain or discomfort
§ Test for volar subluxation: Flex the joint with the proximal phalanx held between the
thumb and forefinger
Functional Assessment of the Hands
§ Pinch grip: “Can you touch your thumb to each finger in turn?”
§ Power grip: “Can you grip my two fingers tightly?”
§ Fine motor control: “Can you show me how you would change a lightbulb?”
§ Fine motor control: “Can you pick up this key for me?”
Special Tests of the Hands
6. Tinel’s Test
§ Repeatedly percuss over the carpal tunnel (ventral wrist)
7. Phalen’s Test
§ Wrist held in flexion for 30-60 seconds
8. Derken’s Test
§ Compress the carpal tunnels for 30-60 seconds
§ More sensitive and specific sign of carpal tunnel syndrome
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Neurovascular Integrity of the Hands
§ Assess power, sensation and special tests
o Median nerve
o Ulnar nerve
o Radial nerve
§ Assess vascular integrity of the upper limb e.g. radial pulse and capillary refill time
Examination of the Face

Eyes
§ Anaemia
§ Cataracts e.g. secondary to long-term steroid use
§ Dry eyes e.g. Sjogren’s syndrome in 10% RA cases
§ Scleritis, episcleritis e.g. rheumatoid lesions affecting the sclera
§ Scleromalacia e.g. scleral thinning in severe RA
§ Fundoscopy
o Hyperviscosity can lead to venous/arterial occlusion
Mouth
§ Dry mouth e.g. Sjogren’s syndrome
§ Ulcers e.g. treatment with gold
Face
§ Parotid gland enlargement e.g. Sjogren’s syndrome
§ Examination of the TMJ joint:
o Pre-auricular swelling
o Palpation from behind the patient: For tenderness, crepitus when patient
opens and closes the mouth
Neck
§ Inspection of the cervical spine for postural abnormalities
§ Palpate spinous processes for any tenderness
§ Active movement, noting any limitation in ROM
§ Offer neurological assessment of the upper limb as cervical spine involvement can
cause neurological deficits
Examination of the Chest
Cardiovascular Examination
§ Pulsus paradoxus (constrictive pericarditis)
§ Elevated JVP (constrictive pericarditis)
§ Impalpable apex beat (constrictive pericarditis)
§ Auscultate for:
o Pericardial friction rub (acute pericarditis)
o Distant heart sounds (pericardial effusion)
o Regurgitant murmurs especially of aortic valve
§ Peripheral oedema (constrictive pericarditis)
Respiratory Examination
§ Palpation:
o Limitation of chest expansion (Fibrosis)
o Unequal expansion (Fibrosis or effusion)
o Tracheal deviation (towards fibrosis – away from effusion)
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§ Percussion: Assess for stony dullness (effusion)

§ Auscultation:
o Reduced or absent breath sounds in the base (effusion)
o Fine pan inspiratory or late inspiratory crackles (Fibrosis)
§ Splenomegaly (occurs in 10% of patient with RA and may suggest Felty’s
syndrome)
§ Hepatomegaly: May occur secondary to Methotrexate treatment
§ Felty’s syndrome:
o Rheumatoid arthritis
o Splenomegaly
o Granulocytopaenia (may develop serious life-threatening infections)
Examination of the Lower Limbs
§ Inspect for rashes, erythema, scars, muscle wasting and joint swelling
§ Examine the hips, knees and foot joints (hips and knee examination to be covered
in ward tutorials)
§ Foot drop [peroneal nerve entrapment or vasculitis]
§ Examine the ankle joint for limitation of movement
§ Signs of cord compression due to anterior dislocation of the first cervical vertebra
or subluxation of the odontoid process. Here upper motor neuron signs occur in the
lower limbs mixed with lower motor neuron signs in the upper limbs
§ Examine the elbows and shoulders, to assess overall upper limb function
§ Perform a complete musculoskeletal assessment
§ Examine other relevant systems if signs present e.g. finger clubbing, palmar
erythema
§ Order relevant investigations e.g. XR hand, ESR/CRP, rheumatoid serology, joint
aspiration
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CHAPTER 7
VASCULAR
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23. Arterial Examination of the Lower Limbs
General Inspection
§ Mental status
§ Breathing distress/comfortable
§ Colour
§ Nutritional status/dehydration
§ Environment
o Devices
o Obvious dysmorphic features (congenital/acquired e.g. amputations)
§ Exposure and positioning: From groin to toes, supine at 45°
Skin:
§ Scars (look at groin) – Most common vascular procedure is a common femoral
endarterectomy
§ Atrophic changes
o Skin: Colour, quality, obvious trauma, swelling, discharge, bleeding, active
infection
o Hair loss
Nails:
§ Onychogryphosis (thickening of the nail), may require toe spacers
§ Tissue loss
o Ulcers
o Gangrene
o Previous amputations
Muscles:
§ Wasting
§ Atrophy
o Calf: Measure 15-20cm down the tibial shaft from the tibial tuberosity,
compare calf with calf
Bones:
§ Deformities
§ Amputations
o Above knee
o Through knee
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o Below knee
o Transmetatarsal
o Digital
Examination of Arterial Ulcer:
§ Site: Soles/pressure areas

§ Depth: Deep
§ Edges: Punched-out
§ Base: Sloughy & pale
§ Colour: Pale
§ Associated features: Painful, loss of peripheral pulses, signs of trophic changes
Palpation of the Lower Limbs
Temperature
§ Backs of both hands
§ Compare both sides
§ Ischaemic leg will be cold
Capillary Refill Time

§ Press the nail of the first toe
§ Should be <2 secs
Buerger’s Test
§ To detect arterial insufficiency
§ Ask the patient if they are in pain
§ Lift the leg up from the bed, inspecting the sole of the foot for pallor of the skin
secondary to arterial insuffiency
§ Buerger’s Angle: The angle at which the ischaemic leg is held when the pallor
occurs
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§ Buerger’s Test: Bring the leg to the edge of the bed and let the foot drop down to
the floor, still inspecting the sole of the foot
§ Positive Buerger’s test occurs with
reactive hyperaemia: Dilatation of
arterioles in an attempt to clear the
accumulation of toxic waste products
(nitrogen, urea, K+) in the blood
secondary to poor arterial supply
Peripheral Pulses
1. Dorsalis Pedis: Draw a line midway
between the medial and lateral malleoli, and
a perpendicular line to the first webspace.
The pulse of the dorsalis pedis artery is in the
proximal 1/3, lateral to the tendon of
extensor hallucis longus
2. Posterior Tibialis: Midway between the
heel and the medial malleolus.
3. Popliteal: Within the popliteal fossa; ask
the patient to flex the knee
4. Femoral: 1.5cm inferior and medial to the
mid-inguinal point, which is midway
between the ASIS and the pubic symphysis
§ Auscultate over the arteries for a bruit
§ Examine the abdomen for AAA
§ Auscultate the heart
§ Perform an ABPI to determine the degree of arterial insufficiency
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24. Venous Examination of the Lower Limbs
General Inspection
§ Colour
§ Devices e.g. medications, mobility aids
§ Exposure and positioning: Supine at 45°, exposed from waist down (shorts) –
consider chaperone
Close Inspection of the Lower Limb
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Signs of Venous Insufficiency

§ Oedema
§ Venous eczema
§ Haemosiderin deposition
o Brown, speckled discolouration
o ‘Cayenne pepper petechiae’
§ Lipodermatosclerosis
o Scarring of subcutaneous fat
o Tight, shiny skin
o ‘Inverted champagne bottle’
appearance (also seen in Charcot-
Marie-Tooth syndrome)
§ Atrophie blanche
o White, scar-like areas
§ Ulceration
o At medial gaiter region
Varicose Veins
Ask the patient to stand

§ Great saphenous vein distribution: Dorsal arch, medial calf, hands-breadth from the
patella, pierces the fascia lata to join the femoral vein
§ Short saphenous vein: Originates from the dorsal arch, drains to the great
saphenous at the popliteal fossa
Saphena Varix
§ Blue-ish lump in groin apparent when standing (may disappear when supine)
§ Caused by dilated saphenofemoral junction secondary to venous incompetence
Examination of a Venous Ulcer

§ Site: Medial gaiter region
§ Depth: Superficial
§ Edges: Sloping
§ Base: Granulation tissue
§ Colour: Pink
§ Associated features: Moderate pain (may be
severe if infection), varicosities, venous
eczema, haemosiderin deposits,
lipodermatosclerosis
Palpation of the Lower Limb

§ Skin texture for lipodermatosclerosis
o Woody
o Hard
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§ Calf tenderness (DVT)

§ Varicose veins for
superficial phlebitis
o Tenderness
o Warmth
§ Saphenofemoral junction
incompetence
o Locate pubic
tubercle
o Approximate
position of SFJ is
2cm inferior and
lateral to pubic
tubercle
o With fingers in this position (or on saphena varix, if present), ask the patient
to cough
o Positive test: Cough impulse (must exclude hernia which can also cause +ve
cough impulse in the groin)
Special Tests
Trendelenburg Tourniquet Test
§ Ask the patient to lie flat
§ Perform straight leg raise, put their
leg onto your shoulder
§ Expedite emptying of the veins by
pushing them towards the groin
§ Apply tourniquet tightly in upper
thigh
§ Ask patient to stand
§ Look for varicosities filling for 10-15
seconds, then release tourniquet
o No filling on standing + rapid filling on release of tourniquet: Isolated SFJ
incompetence
o Slow filling on standing + rapid filling on release of tourniquet: Mixed SFJ
and perforating vein incompetence
§ Examine the lower limb arterial system
§ Perform a lower limb neurological examination
§ Perform Perthes test
§ Order relevant investigations e.g. Doppler US to identify sites of incompetence
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25. Vascular Examination of the Abdomen
General Inspection
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§ Colour
§ Nutritional status/dehydration
§ Environment
o Devices
o Obvious dysmorphic features
(congenital/acquired e.g. amputations)
§ Exposure and positioning: Flat in the bed, exposed
from nipple to knee ideally, but exposure to waist
for px modesty is fine
Close Inspection of the Abdomen*
*Bend to one knee and observe from the bedside
§ Visible pulsation in the epigastric area
Palpation of the Abdomen
§ Palpate over the area to examine whether it is palpable
§ Determine:
o Lateral borders
§ Place left hand on the flank and move
the right hand in towards midline
§ Establish left border of the pulsation
§ Move the left hand in steadily to
determine the right border of the
pulsation
o Diameter
§ Measure with tape the approximate diameter
o Pulsatile
§ Comment whether pulsatile or not
o Position
§ Place left hand below the xiphisternum
§ If you can get above the aneurysm, it implies it is an infra-renal
aneurysm
Auscultation of the Abdomen
§ Renal bruits: Above the umbilicus, 2cm either side of the midline
§ Perform a full vascular examination of the upper and lower limbs
o Peripheral pulses
o Buerger’s test
o Trendelenburg test
o ABPI
§ Perform a full cardiovascular examination
§ Assess the carotids
o US abdomen
o Doppler US (peripheral vessels)
NOTES
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CHAPTER 8
GENITOURINARY SYSTEM
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26. Clinical Examination of the Renal System and AV Fistula
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General Inspection
§ Altered mental status e.g. uraemic encephalopathy
§ Breathing e.g. hyperventilation (may indicated metabolic acidosis)
§ Colour e.g. uraemic tinge/slate grey/bronze (due to iron deposition in dialysis px
who have received multiple transfusions)
§ Circulation e.g. hydration status/volume overload
§ Devices e.g. central lines, Tenckhoff catheter, oxygen, medications
§ Exposure: To the waist, supine at 45°
Close Inspection of the Hands and Wrist
Nails
§ Clubbing
§ Koilonychia (anaemia of chronic disease)
§ Terry’s nails
§ Vasculitic nail changes
§ Bowe’s lines
o Transverse pigmentation of the nails due to
malnutrition – hypercatabolic state
§ Muehrcke’s nails
o Two paired white transverse lines which run parallel
to the lunula on the nail
o Hypoalbuminaemia e.g. Nephrotic syndrome
§ Leuconychia
o Aetiology: Hypoalbuminaemia e.g. Nephrotic
syndrome
Dorsal Surface of the Hands

§ Uraemic tinge
o Sallow complexion due to impaired
excretion of urinary pigments combined
with anaemia
§ Uraemic frost
o White powder-like deposition in advanced
uraemia
§ Capillary refill time
o Ischaemia secondary to Steal syndrome in
failed AV fistula
Palmar Surface of the Hands

§ Pallor of palmar creases (anaemia of chronic disease)
§ Scars e.g. Carpal tunnel release scar
§ Wasting of the thenar eminence e.g. CT syndrome
Wrist
§ Flapping tremor (uraemic encephalopathy)
§ Radial pulse
o Rapid assessment of circulatory status
Close Inspection of the Arms
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Skin
§ Excoriations/scratch marks
o Uraemic pruritus
§ Colour
Parathyroid Implantation Scar

§ Also check the neck for parathyroidectomy
scar
Blood Pressure
§ Manual BP (supine and standing)
§ Do not examine on the side with AV fistula if present
Examination of AV Fistula*
§ Inspection:
o Longitudinal swelling
o Vascular mass
§ Characteristics of the fistula: 
o Site: Radiocephalic, brachiocephalic
o Size: 2-3cm wide, 6-8cm long 
o Shape: Cylindrical
o Skin changes: Redness/oedema/bruising/infection/abscess/drainage
o Stigmata: Previous needling
o Signs of failure: Additional IV access e.g. central line, previous scars
§ Palpation:
o Temperature (with back of hand)
o Tenderness
o Thrill (palpable murmur): Should only be at site of anastomosis
o Site of maximal impulse: Palpate from the wrist upwards to the site of
maximal pulsatility
§ Auscultation:
o Listen for bruit
o Continuous, machinery-like murmur(diastolic + systolic) - louder in systole
o If stenosis present, bruit may be discontinuous/high pitched/“whistling”  
§ Assessment for complications:
o Signs of infection
§ Erythema
§ Swelling
o Aneurysm/pseudoaneurysm
o Haematoma
o Thrombosis
o Stenosis (turbulence, pseudoaneurysm, injury to vessel wall)
o Steal syndrome: Arterial insufficiency distal to haemodialysis AV access
(look for evidence of ischaemia distal to the fistula)
§ Special Tests:
o Raise arm test
§ Test for outflow stenosis
§ Ask the patient about pain in the arm
§ Elevate the arm above the level of the heart
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Medicine
§ AV fistula should collapse – no outflow stenosis

§ Positive test: Fistula remains bulging when the arm is elevated,
indicating outflow stenosis
o Augmentation test
§ Test for inflow stenosis
§ Occlusion of the outflow tract by compression of the proximal arm
along the vascular pathway
§ Thrill should become a strong pulsation
§ Positive test: Failure of augmentation of the pulse, indicative of
inflow stenosis
o Allen’s test
§ To assess for vascular integrity
*Principles of an AV Fistula:
§ Definition: Surgical creation of an anastomosis between an artery and a vein –
leads to venous engorgement and enlargement 
§ Indications: Allows large bore needles to be inserted for haemodialysis
§ Sites:
o Radio-cephalic
o Brachio-cephalic
o Upper arm basilic-brachial fistula
§ Characteristics:
o Rule of 6’s ( If one of these is not present the fistula will not be used)
§ Minimum of 6mm in diameter when a tourniquet is placed  
§ Maximum 6mm deep  
§ Should accommodate flow of 600mls/min  
§ Matures in 4-6 weeks  
In Summary:
§ Functioning fistula, needling, no renal transplant
§ Longitudinal mass in the left arm, vascular in nature, antecubital fossa
§ I would like to assess for signs of AV fistula failure and decompensated renal disease
§ Examine for peripheral neuropathy
Skin
§ Cushingoid appearance
§ Malar rash of SLE
§ Pallor (anaemia of chronic disease)
Eyes
§ Xanthelasma (hypercholesterolaemia)
§ Corneal arcus (hypercholesterolaemia)
§ Anaemia of conjunctivae (anaemia of chronic
disease)
Mouth
§ Hydration status
o Dry/wet mucous membranes
§ Uraemic fetor
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o Due to breakdown of urea to ammonia in the

saliva
§ Mucosal ulcers
o Decrease in saliva flow in px with CKD
§ Thrush
o Decreased acute inflammatory response due
to nitrogen retention
§ Candidiasis
o Secondary to immunosuppression
§ Gingival hypertrophy
o S/E of immunosuppressants (e.g. tacrolimus/cyclosporin) in post-transplant
patients
§ Parathyroidectomy scar
§ Central line/previous IV line scars
o Haemodialysis access
§ Jugular venous pressure
o To assess the intravascular
volume status
§ Carotid artery bruits
o May suggest generalised
atherosclerotic disease, which
can cause RAS or complicate
CKD
§ Acanthosis nigricans
o At the axillae
o Consistent with diabetes mellitus
Inspection of the Abdomen
§ Scars
o RIF/LIF (transplant scars)
o Back
(nephrostomy/nephrectomy)
§ Abdominal distension
o Ascites
§ Fluid retention
§ Peritoneal dialysis fluid
§ Nephrotic syndrome
o Polycystic kidney disease
§ Colour: Uraemic tinge
§ Visible mass e.g. renal transplant in LIF/RIF
§ Devices in situ e.g. Tenckhoff catheter
Palpation of the Abdomen*

*Get down on one knee, keep watching px face, and advise the px “Tell me if I cause you
any discomfort.” Be sure to start furthest from any area of discomfort/pain
§ Superficial palpation
§ Deep palpation
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Medicine
Examination of the Kidneys

§ Ballotment
o Renal tenderness: Acute rejection in post-transplant px/renal colic in px
with abdominal pain
§ Palpation of transplanted kidney
§ Differentiate left kidney from spleen if necessary
o Kidney is ballotable
o Hand can get above a kidney
o Percussion note is resonant over a kidney
o Spleen moves more with respiration
o Spleen has a notch
Percussion of the Abdomen

§ Liver span (if enlarged kidney appreciated)
o Px with polycystic kidneys may also have hepatic cysts
§ Bladder
o Bladder enlargement
Assessment for Ascites: Shifting Dullness

§ Only if Tenckhoff catheter in situ
§ Percuss away from midline towards L flank
§ Leave finger at first point of dullness
§ Roll px towards you
§ Percuss again
§ Positive test: Tympanic percussion note on
shifting of the px
Auscultation
§ Renal bruits
o Above the umbilicus, 2cm lateral (L/R) of the midline
o Listen with the diaphragm
§ Lung bases
o Bibasal crepitations
§ Peripheral oedema
o Palpate for sacral oedema
o Palpate for pitting oedema
§ Perform a full gastrointestinal examination
o To assess for scrotal masses/genital oedema
o To assess for AAA
§ Perform a complete cardiovascular and respiratory examination
o To assess for signs of CCF
o To assess for pericardial rub
§ Pericarditis secondary to retained metabolic toxins, leading to
pericardial effusion
o To assess for pulmonary oedema
§ Examine the lower limbs
o To examine for vasculitic signs e.g. purpura/livedo reticularis (red-blue
reticular pattern from vasculitis/atheroembolic disease)
o To assess for signs of peripheral vascular disease
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§ Examine for diabetic complications e.g. fundoscopy, peripheral neuropathy, BP

o Bedside: Urinalysis, ABG
o Bloods: FBC, RFTs, LFTs
o Imaging: US abdomen + pelvis +/- CXR
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References
§ Clinical Examination: A Systematic Guide to Physical Diagnosis. 7th
Edition. Talley, N., O’Connor, S.
§ Essential Examination. 3 edition. Ruthven, A.K.B.
rd
§ Muirne Spooner Lecture Series, for the Royal College of Surgeons in

Ireland, 2018
§ Clinical Examination Notes, School of Medicine for the Royal College of
Surgeons in Ireland (2015-2018)
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RCSI Clinical Examinations

Medicine 2018-19
Checklist
No. Examination Done
1 Clinical Examination of the Cardiovascular System
2 Clinical Examination of the Respiratory System
3 Clinical Examination of the Gastrointestinal System
4 Clinical Examination of a Stoma
5 Clinical Examination of a Hernia
6 Neurological Examination of the Upper Limb
7 Neurological Examination of the Lower Limb
8 Clinical Examination of the Gait and Cerebellum
9 Clinical Examination of Speech
10 Clinical Examination of Higher Order Functioning
11 Clinical Examination of Parkinson Disease
12 Clinical Examination of the Cranial Nerves
13 Clinical Examination of the Thyroid Gland
14 Clinical Examination for Acromegaly
15 Clinical Examination of the Breast
16 Clinical Examination of the Diabetic Patient
17 Surgical Examination of the Hands
18 Musculoskeletal Examination of the Hip
19 Musculoskeletal Examination of the Knee
20 Musculoskeletal Examination of the Shoulder
21 Musculoskeletal Examination of the Spine
22 Clinical Examination of Rheumatoid Arthritis
23 Arterial Examination of the Lower Limbs
24 Venous Examination of the Lower Limbs
25 Vascular Examination of the Abdomen
26 Clinical Examination of the Renal System and AV Fistula
188

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CLINICAL EXAMINATIONS

Royal College of Surgeons in Ireland

Senior Cycle 2 | 2018-19

1. Clinical Examination of the Cardiovascular System

o Cardiovascular causes of clubbing:

Palmar Surface of Hands:

o Rate: 60-100 BPM

Causes of an Absent Radial Pulse:

Mucous Membranes - Lips and Tongue:

o Caused by reduced arterial oxygenation as defined as >5g/dL deoxygenated

Jugular Venous Pressure (JVP):

• Fluid overload (if someone has forgotten to take IV out)

Features of Elevated JVP:

Causes of Elevated JVP:

o Thoracotomy [mitral valvotomy - a stenosed mitral valve is opened through

§ To locate position of apex beat count down the number of interspaces

o Apex beat may be displaced laterally or inferiorly or both

Causes of Impalpable Apex Beat:

Causes of Displaced Apex Beat:

§ This is present in right ventricular enlargement/hypertrophy

1. Mitral (apex beat): 5 left ICS MCL

2. Tricuspid (LLSB): 4 left ICS, left

4. Aortic: 2 ICS, right sternal edge

S1: Mitral and tricuspid valve

Between S1 – S2: Systole

Grade Description of Murmur

Prosthetic Heart Valves

§ Mitral valve: Congruent with 1 HS, asynchronous with systole

Differential Diagnosis for Cardiac Murmurs

2. Clinical Examination of the Respiratory System

§ Respiratory causes of clubbing:

o Pulsus paradoxus: Decrease in pulse pressure by >20mmHg on inspiration

thyrotoxicosis and SVC obstruction)

normal haemoglobin level

Close Inspection of the Neck

§ Displaced towards side of the lung lesion

§ Often a gap is present between inspiration and expiration

Right lower Left lower lobe

§ Added sounds e.g. wheeze/crackles

Examination of Lower Limbs

3. Clinical Examination of the Gastrointestinal System

Close Inspection of the Wrist and Arms

Mouth & Tongue

Oral Candida Glossitis

Jugular Venous Pressure

Close Inspection of the Abdomen*

Palpation of the Liver

Palpation of the Spleen

Palpation of the Kidneys: Ballotment

Abdominal Aorta: Assessment for AAA

§ Check for an abdominal aortic

§ The normal liver span is about 12.5cms

Assessment of Ascites: Shifting Dullness

Assessment of Ascites: Fluid Thrill

§ Absence of bowel sounds:

4. Clinical Examination of a Stoma

5. Clinical Examination of a Hernia

§ If the hernia reappears, it is a direct hernia (protruding through

6. Neurological Examination of the Upper Limb

§ Contraction of the biceps muscle occurs and flexion of the forearm