Specific Checklists

Examination of a Lump
Focused Examination History
1. Site
2. Size
3. Shape
4. Temperature
5. Tenderness
6. Surface (smooth, irregular)
7. Edge (defined or indistinct)
8. Color and texture of overlying skin
9. Consistency (solid , cystic)
10. Mobile or fixed (assess axis of mobility)
11. Perform fluctuation
12. Perform fluid thrill
13. Perform translucency test
14. Assess for resonance
15. Assess for pulsation or transmitted pulsation
16. Assess for compressibility
17. Assess for reducibility
18. Looked for audible bruit
19. Relation to skin
20. Relation to underlying muscles
21. Relation to deeper structures
22. State of regional lymph nodes (palpable or not, tender, soft, firm or hard)
23. State of local tissue (skin and subcutaneous tissue, muscles, bones)
24. Local circulation
25. Local sensation

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 Abdomen, umbilicus and abdominal wall
examination
Focused Examination:
1. Relax the abdomen
2. Inspected for cachexia
3. Pallor
4. Jaundice
5. Shape of the abdomen; Symmetry of the abdominal wall
6. Movements with respiration
7. Scars
8. Sinus
9. Fistula
10. Distended veins
11. Discoloration
12. Umbilicus (position, shape and abnormalities)
13. Hernia orifices
14. Palpation; superficial for masses and tenderness
15. Palpation; deep for deep tenderness
16. Deep masses
17. Solid organs
18. Percussion; dullness (identify normal dullness zones)
19. Cystic Vs solid mass
20. Fluid thrill
21. Shifting dullness and transmitted thrill for ascitis
22. “Pointing” test or local Vs generalized tenderness
23. Auscultate for bowel sounds
24. Auscultate for systolic bruit (renal, aortic or iliac arteries)
25. Extra abdominal; neck
26. Extra abdominal limbs
27. Extra abdominal spine
28. Extra abdominal hernia orifices
29. Extra abdominal; external genetilia
30. DRE (inform intention to do it)

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 Dysphagia
Focused History Taking
1. Follow a chronological order
2. onset
3. Hematemesis / Malena
4. Wight loss
5. Sticking of food
6. Difficulty initially with solids then liquids
7. Painful or painless Dysphagia
8. Regurgitation
9. Position that aggravate regurgitation
10. Smell, taste, and nature of regurgitated material
11. Bowel movement / diarrhea, constipation
12. Anemia
13. Fever / chills / night sweats
14. Abdominal pain / mass
15. Heart burn
16. Nausea / vomiting
17. Chest pain
18. Medication use
19. Cough
20. Hoarse voice
21. Pneumonia or any respiratory infections
22. Aspiration and chalking spills
23. Past medical history
24. Past surgical history
25. Family history
26. Social history: work, smoking, alcohol, eating habits and life style

Physical examination
1. Wash and warm hands
2. Consent of examination
3. Ensure patient properly draped
4. Check mouth for loss of enamel, thrush, aphthous ulcer
5. Check throat
6. Check cervical and supraclavicular lymph nodes
7. Abdomen: looks for epigastric tenderness / mass, liver
8. Auscultate chest
9. Verbalize the maneuvers on the examination
10. Give attention to patient physical comfort

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 Peptic ulcer
Introduction
1. Self introduction and Permissions
2. Greeting the patient by first name, shake hands
3. Negotiate an agenda
4. Establish a plan for the visit
5. Proper uncovering when needed
6. Appropriate tools available (Stethoscope, Torch light, Woody Spatula,
Gloves, hammer and Thermometer)
7. Bed side behavior during examination
8. Patient Mental status (Consciousness)
9. Concentration and orientation
10. Position in bed

Focused History taking:

1. Location
2. Intensity, quality
3. Onset
4. Aggravating factors
5. Relieving factors
6. Radiation
7. Dizziness
8. Alcohol
9. Bleeding Hematemesis , Malena
10. Bowel movement, flatus
11. Urinary symptoms
12. Previous episodes
13. Medication/ NSAIDs and aspirin or steroids
14. Past history, endoscopy, surgery
15. allergies

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 Peptic ulcer
Focused clinical examination
1. Wash hands
2. Consent for examination
3. Ensure patient properly draped
4. Relevant general hydration
5. Pulse
6. BP
7. Look for signs of anemia
8. Inspection
9. Auscultation
10. Percussion
11. Peritoneal signs
12. Palpation
13. DRE (intention voiced)
14. Give attention to patient physical comfort
15. Verbalize the maneuvers on the examination

Management:
1. Level of consciousness
2. Airways and Breathing
3. Circulation
4. Vitals: Pulse, BP, Temp, RR
5. NPO

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 Infantile Hypertrophic Pyloric stenosis
Focused history taking
1. When did the vomiting start?
2. How many episodes per day?
3. Any relation to feeds?
4. Character of the vomitus and volume
5. Number of wet diapers
6. Number and character of stool, any blood
7. Sleep disturbances
8. Weight gain relative to birth weight
9. Birth history
10. Family history
Examination:
1. alertness
2. activity
3. temperature
4. sunken fontanels
5. vigorous suck
6. abdominal soft ,tender
7. any organomegaly
8. papillary refill
Acute Cholecystitis
Focused history taking:
1. Present illness onset
2. Location of pain
3. Quality
4. Radiation
5. Severity
6. Timing related to food
7. Aggravating factors
8. Relieving factors
9. Associated fever
10. Nausea / vomiting
11. Change in bowel motion
12. Blood in the stool
13. Wight loss
14. Urinary symptoms
15. Possibility of being pregnant / Vaginal discharge
16. Past history of previous episodes
17. Past surgical history
18. Social history of alcohol / Smoking / diet
19. Drugs

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 Gall stones
History-Taking
1. Site
2. Onset, duration, course
3. Quality and Quantity (on a scale of 1-10)
4. Aggravating factors
5. Relieving factors
6. Radiation
7. Nausea or vomiting (frequency, amount and character)
8. Fever, chills
9. Bleeding per-rectum, Malena
10. Bowel movement, flatus
11. Urinary symptoms
12. Previous episodes
13. Medications; NSAI use
14. Past history; similar attacks, endoscopies, surgery
15. Family history

Management:
1. Level of consciousness
2. Airways and Breathing
3. Circulation
4. Vitals: Pulse, BP, Temp, RR
5. NPO

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 Acute appendicitis
History-Taking
1. Site
2. Onset, duration, course
3. Quality and Quantity (on a scale of 1-10)
4. Aggravating factors
5. Relieving factors
6. Radiation
7. Nausea or vomiting (frequency, amount and character)
8. shifting pain: start as visceral pain (around the umbilicus) then shift to parietal
pain (in the R.I.F )
9. Loss of appetite
10. Diarrhea or constipation

Examination:
1. Rovsing's sign: pressure on left iliac fossa and the pain will appear in Right
iliac fossa
2. McBurney's sign: deep tenderness at the McBurney's point
3. Obturator sign: pain due to contact between the inflamed appendix and
obturator muscle.
4. Psoas sign: The pain results because the psoas borders the peritoneal cavity,
so stretching (by hyperextension at the hip) or contraction (by flexion of the
hip) of the muscles causes friction against nearby inflamed tissues like
appendix.
5. Aaron's sign: is a referred pain felt in the epigastrium upon continuous firm
pressure over McBurney's point. It is indicative of appendicitis
6. pressure on the abdominal wall. It is very similar to rebound tenderness
7. Cough sign: increase pain with cough because of parietal pain
8. Shifting pain
9. Shifting tenderness: pressure on left iliac fossa and the pain will appear in
Right iliac fossa
10. R.I.F Tenderness
11. Rebound tenderness: lead to sever pain after sudden release of the hand
above appendix
12. percussion tenderness: percussion on McBurney's point lead to sever
tenderness
13. guarding sign: The tensed muscles of the abdominal wall automatically go
into spasm to keep the tender underlying tissues (apeendix) from being
disturbed.

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 Diabetic Foot
History taking:
1. When diabetes diagnosed?
2. How it had been diagnosed as a diabetic?
3. What treatment he/she was on?
4. What is the treatment he/she is on now?
5. Any incident of hypoglycemia?
6. Any incident of hyperglycemia?
7. Is he/she on regular follow up program? (diabetic clinic)
8. How he/ she started the foot problem?
9. Is he/she feels his/her foot?
10. What kind of treatment he/she received (if any)?
Clinical examination:
1. Inspection / General / gait, shoes, heels,
2. Any foot ulcer or deformity?
3. Inspection / skin / vascular insufficiency-hairlessness, pallor
4. Rubor at pressure points
5. Skin breakdown (portal for infection)
6. Diabetic dermopathy (brown macules) over shins
7. Infection; cellulites (erythema, swelling),
8. Gangrene
9. Web spaces; cracked, infected, ulcer, maceration
10. Toe nails; dystrophic, in-grown, paronychia, onychomycosis
11. Palpation / pulses/ femoral
12. Palpation pulses / popliteal
13. Palpation pulses / posterior tibial
14. Palpation / pulses / dorsalis pedis
15. Temperature / use back of hand/ compare shin to feet bilaterally
16. Capillary refill
17. Auscultation / bruits; femoral and popliteal
18. Neurological / sensory / vibration
19. Neurological / sensory / light touch
20. Neurological / sensory / pin prick
21. Neurological / sensory / proprioception
22. Neurological / sensory / temperature
23. Neurological / sensory loss in "glove and stocking" distribution
24. Autonomic/ sweating
25. Autonomic / Dry cracked skin
26. Autonomic / scaling
27. Motor / intrinsic muscle wasting (clawed, hammer toes)
28. Motor / Pes planus, Pes cavus
29. Motor / charcot joints
30. reflexes / ankle jerk, knee jerk

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 Trauma
History taking
1. Duration of present illness (trauma): from the start of trauma until now or
until admition
2. describe the accident event:
3. Type of accident
4. Was he the walker (on the street, sidewalk), driver, passenger (front or back
seats),
5. protection (seat belts, airbags)
6. Others in the area of accident (relatives or combines)
7. Type of car and its speed (low or high velocity)
8. Damage to the vehicle: collision, rolling
9. Type of instrument hit him
10. Loss of conscious
11. Pain
12. Wound
13. Bleeding
14. Vomiting
15. Urination
16. cough
17. Dyspnea.
18. Time of arrival to the hospital
19. I.V fluid
20. Bandage
21. Antibiotics
22. Stop of bleeding
23. Walking after accident
24. Transportation: car, ambulance
25. The distance of the hospital
26. What resuscitation and procedures done? What organs was damaged.
27. Type of machine: low velocity (pistol), high velocity (gun)
28. Number of bullets
29. Distance from shooter
30. Site of inlet and outlet
31. Fall from a height: Height of fall, Did the patient hit anything on his way,
What position was the body at time of impact?

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Examination and Management:
1. Ask for vital signs
2. Wash hands
3. Solicited consent for examination
4. Explain about the procedure to be performed
5. Ask for C-Spine precautions
6. Ask for 2 large bore IV lines
7. Ask for oxygen
8. Ask for monitors
9. Ask for appropriate fluid boluses
10. Check airways
11. Recognize cyanosis
12. Inspect chest
13. Palpate chest for subcutaneous emphysema
14. Palpate chest for Fractured rib(s)
15. Auscultate chest for air entry
16. Feel for tracheal position
17. Recognize hemopnemothorax
18. Treat correctly hemopnemothorax
19. Reassess chest after chest tube or needle decompression
20. Reassess vital signs
21. Look for external sources of blood loss
22. Check the abdomen for possible abdominal hemorrhage
23. Examine pelvis
24. Examine long bones for fractures
25. Assess GCS
26. Exposed patient and log roll and DRE, indicate options to determine intra
abdominal hemorrhage (DPL, FAST, CT)
27. Asked AMPLE history
28. Demonstrate competent approach to the ABCDE survey
29. Verbalize the maneuvers on the examination
30. Give attention to patient comfort and modesty

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 DVT
History taking:
1. Onset of pain
2. Trauma to the leg
3. Fever
4. Chest pain
5. Shortness of breath
6. Pregnancy
7. Recent immobilization (long trip seated)
8. Occupation
9. Past medical history
10. Past surgical history
11. Medications
12. Smoking
13. Drug use
14. Alcohol consumption
15. Family history of blood clots

Examination:
1. Wash hands
2. Solicited consent for examination
3. Explain the procedure to be performed
4. Check leg for tenderness
5. Check temperature
6. Check the pulses
7. Check for Hoffman’s sign (calf pain with dorsiflexion of foot)
8. Listen to the lungs in four places
9. Verbalize the maneuver on examination
10. Give attention to patient’s physical comfort

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 Varicose veins and DVT
General Examination:
1. Pulse; Both arms (Rate, Rhythm, Volume, Character and Nature of the wall)
2. BP; both arms
3. Anemia
4. Dyspnoea
5. Signs of CHF

Focused Examination:
1. Asymmetry; both limbs, Early ankle edema
2. Both limbs temperature and circumference
3. Tender calf muscle (Homon’s sign)
4. Tenderness in the thigh along femoral vein
5. Superficial thrombophlebitis
6. Whole limb inspection for varicose veins
7. Swelling at site of perforators
8. Skin pigmentations
9. Pre-ulcerative lesions Vs established venous ulcer
10. Identify long Vs short saphenous varicosity
11. “Cough impulse” test (incompetent valves of long saphenous system)
12. Percussion or “Tap sign” test (incompetent valves of long saphenous system)
13. “Brodi-Trendelnberg” test (incompetent sapheno-femoral and/or
perforators)
14. “Fegans” test marking perforator sites
15. “Perthe’s” test for patency of deep veins

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 Goiter
Focused History:
1. Age and sex
2. Locality
3. Duration of the swelling
4. Change in size
5. Pain
6. Fever
7. Anxiety; sleep disturbances Vs lethargy; sleepiness and hypotonia
8. Tachycardia, palpitations
9. Diarrhea Vs constipation
10. Menstrual disturbances; menorrhagia Vs oligo or amenorrhea
11. Miscarriages and infertility
12. Intolerance to hot Vs cold whether
13. Sweaty palms and skin Vs dry scaly skin
14. Change in voice, change in speech pattern
15. Dietary habits; goiterogenes
16. Respiratory obstruction
17. Drugs; antithyroids
18. Irradiation exposure
19. Past medical history; cardiac troubles
20. Family history of goiter

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 Goiter
Focused Examination:
1. Inspection; confirmed the presence of a neck swelling
2. Asked patient to swallow
3. Asked patient to protrude tongue
4. Observed for restlessness; agitation, sitting unstill
5. Observed for lethargy, hypotonia
6. Speech and voice
7. Body build and temperature
8. Moist palms
9. skin
10. Tremor
11. Pulse and BP
12. Examined for eye signs; lid lag
13. Lid retraction
14. Exophthalmos
15. Ophthalmoplagia and chemosis (malignant exophthalmos)
16. Palpation; from the front and from back
17. Size
18. Shape
19. Surface
20. Consistency
21. Symmetry
22. Mobility Vs fixity
23. Tenderness
24. Deviation of thyroid cartilage
25. Carotid pulsation
26. Position of the trachea
27. Examined for possible retrosternal extension
28. Auscultate for bruit; vascular goiter
29. Looked for Horner’s syndrome
30. Cervical including supraclavicular lymph nodes

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 breast mass; nipple discharge
Focused History:
1. Age
2. Married or single
3. Party
4. When first felt mass; localization by patient
5. Pain; localized, generalized, unilateral or bilateral
6. Associated nipple discharge; nature
7. Menstruation
8. Radiation exposure
9. Social status; stress
10. Family history; breast cancer
Focused examination:
1. Inspection; both breasts for size
2. Symmetry
3. Skin changes
4. Congenital anomalies
5. Nipple and areola; presence Vs absence
6. Color
7. Symmetry
8. Discharge; nature; from which duct
9. Retraction
10. Destruction
11. Deviation
12. “peu de orange” sign
13. Inspection; axillae and supraclavicular fosse and arms; swellings
14. Enlargement
15. Distended veins
16. Wasted muscles
17. Raising arms above head; for mass
18. Press arms against hips; for mass
19. Palpation; properly by palmer surface of fingers- nature of mass
20. Size
21. Site; which quadrant
22. Shape
23. Surface
24. Consistency
25. Fixity; to skin or to deep chest wall
26. Relation to nipple discharge; if any
27. Circumferential areola palpation; nipple discharge
28. Bilateral Axillary and supraclavicular lymph nodes examination
29. Chest and abdominal examination
30. Spine; local tenderness over the lower lumbar spine

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 Groin Hernia
Focused History:
1. Age and sex
2. Occupation
3. Parity (for females)
4. When first noticed?
5. Increase in size with muscular efforts, cough, straining
6. Reducible? Spontaneous, by patient or by attending doctor
7. Irreducible? Pain or no pain
8. Associated symptoms; abdominal pain
9. Fever
10. Fullness, bloating
11. Dyspeptic symptoms
12. Nausea, vomiting
13. Chronic constipation
14. Urinary symptoms
15. Chest; chronic repetitive cough
16. Past medical; diabetes, jaundice, tuberculosis, ascitis
17. Drug history; steroids, cytotoxic
18. Social history; smoking
19. Family history; "congenital hernia"
20. Gynecological history; party

Focused Examination:
1. Inspection; expansible cough impulse
2. Palpation; expansible cough impulse
3. Ascertaining site, above or below inguinal ligament
4. Direct or indirect inguinal
5. Reducible or not
6. If scrotal; getting above it or not
7. If scrotal; transillumination
8. Feeling testis; relation to swelling
9. Any testicular abnormalities; absence, maldescent, undescended, ectopic
10. Tenderness over the hernia
11. Skin changes
12. Possible contents (bowel, omentum, others)
13. Percussion and auscultation; dullness, resonance, any bruit
14. Chest examination
15. Abdominal examination

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Abdominal pain history
Take a focused history?

1. Introduction and orientation

2. Asks about nature of abdominal pain.
3. site and shifting
4. onset & the way of the pain coarse
5. severity and it's effect on the paitent
6. duration
7. radiation
8. aggravating and alleviating factors
9. associated symptoms and signs
10. Change over time
11. Enquires specifically about: fever
12. loss of weight or anorexia
13. dysphagia
14. indigestion
15. nausea, vomiting, and haematemesis
16. diarrhoea or constipation
17. melaena or rectal bleeding
18. steatorrhoea
19. jaundice
20. genitourinary symptoms
21. history of previous attacks
22. Past medical history, key aspects
23. Drug history
24. Family history
25. Social history

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Chief complaint: neck swelling for 1 month duration
HPI:
Patient’s condition started 1 month ago when she accidently discovered a
small swelling in the frontal aspect of the neck on the right side while she was
looking at herself in the mirror. The swelling is painless. No specific factors
that increase or decrease the swelling. There are no associated symptoms
such as shortness of breath, difficulty swallowing, hoarseness of voice,
palpitation, changes in the weight, changes in the appetite, changes in bowel
motion, changes in the menstruation, heat or cold intolerance, fatigue, sleep
disturbances, nervousness.
The swelling gradually increased in size over the last month.
The patient visited a private doctor which examined her and referred to the
hospital for admission for surgical biopsy.
In the hospital, blood investigations were done and the patient is waiting for
surgery.

Operative Hx
History taking:

Ask about the following:

- Name & reason of the operation.
- Time of admission to operating theater.
- Type of anesthesia.
- Blood transfusion.
- Known complications (note  some doctors would not agree on asking
this question because the patient is unconscious and unaware of the
complications).
- Time of discharge from operating theater.
- Time of regaining consciousness.

Example:
Op Hx: The patient was admitted to the operating theater at 9:00 AM for
elective cholecystectomy. The operation was done under general anesthesia.
There were no known complications & no blood transfusion. The patient was
discharged from the operating theater at 10:30 AM. She regained partial
consciousness at 10:30 AM and full consciousness at 11:30 AM.
Post-op Hx
History taking:

Ask about the following points and repeat them every day starting from
day 0 (day of operation):
- Fever (review the causes of post-op fever, below).
- Nausea and vomiting (causes: pain, opioids analgesics, paralytic ileus,
and anesthesia).
- Oral intake: solid and liquid.
- Cough/sputum (causes: anesthesia, chest infection).
- Dyspnea.
- Chest pain.
- Pain at site of operation: excessive pain maybe caused by wound
infection.
- Wound discharge or bleeding.
- Passage of flatus or stool (indicates the return of GIT function).
- Passage of urine.
- Mobility (i.e. does the patient get up and start walking? prolonged
immobility is bad  DVT).
- Pain in the legs (may indicate DVT).
- Tubes & Drains: e.g. Foley catheter, nasogastric tube (NG tube), surgical
drain.
- Treatment received: Drugs & IV fluids.

Example:
Post-op Hx:
- Day 0: the patient had cough, sputum, mild pain at the the site of
operation. But there was no fever, no nausea or vomiting, no oral intake,
no chest pain, no shortness of breath. She passed urine but hasn't passed
flatus or stool. No leg pain & hasn't started mobilizing yet. She received IV
fluids & IV medications.

- Day 1: No fever, no nausea or vomiting, no cough, no chest pain or

dyspnea, she passed flatus and stool & oral intake was resumed in the
form of liquid & soft food (e.g. orange juice & biscuit). The pain is
 decreased at the site of operation. The patient started walking in the ward
and going to bathroom. She received IV fluids & IV medications.

- Day 2: no fever, no nausea or vomiting, no cough, no chest pain or

shortness of breath, mild pain at operation wound, normal oral intake,
normal passage of stool and urine, no leg pain and normal mobility.

Notes
Criteria of colicky pain:
- Intermittent.
- Hollow viscus
- Smooth muscles
- Peristalsis.
- Distal obstruction.

Seen in the following organs: bowel, ureters, fallopian tubes, biliary tree, &
salivary glands ducts.

Causes of post-op vomiting:

- Pain: stimulation of chemoreceptor trigger zone.
- Drugs: narcotics; morphine. Prescribe an antiemetic with the narcotics.
- Effect of anesthesia.
- Paralytic ileus.

Note  The term acute abdominal pain generally refers to previously

undiagnosed pain that arises suddenly and is of less than 7 days' (usually less
than 48 hours') duration.

Ballotable organs:
- Kidney.
- Gravid uterus.
- Ovarian cyst.

Note  Auscultation for bowel sounds: 5 cm below & right to umbilicus &
wait for 2 minutes. Normal bowel sounds 8\minutes.
Note  Renal angle tenderness examination by thumb & fist.