2. Abdominal Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed (ideally nipple to knee)
- Look for medical equipment / therapies (e.g drains, colostomy / ileostomy bags,
dietary status)
- General inspection of patient:
- General comfort
- Lying very still (peritonism) or writhing in pain (renal stones)
- Signs of liver disease (e.g. jaundice, scratch marks, ascites)
2) Inspection of hands and arms
- Clubbing (e.g. inflammatory bowel disease, coeliac disease, cirrhosis)
- Hypertrophic pulmonary osteoarthropathy
- Koilonychia (iron deficiency)
- Leukonychia (hypoalbuminaemia)
- Capillary refill
- Dupytren’s contracture
- Palmar erythema
- Palmar creases (pale in anaemia, pigmented in Addison’s disease)
- Asterixis (hepatic encephalopathy)
- Dialysis fistulae
3) Palpation of hands and arms
- Radial pulse
4) Inspection of head and neck
- Eyes
- Conjunctival pallor
- Icterus (look at top of sclerae)
- Kayser-Fleischer rings (Wilson’s disease)
- Mouth
- State of dentition
- Angular stomatitis (inflammatory bowel disease)
- Aphthous ulcers (vitamin B12 / iron deficiency)
- Atrophic glossitis (vitamin B12 / folate / iron deficiency)
- Pigmentation of oral mucosa (Peutz-Jegher’s syndrome)
- Telangiectasia
- Candidiasis
- Fauces
- JVP
5) Palpation of head and neck
- Virchow’s node (left supraclavicular lymphadenopathy – gastric / abdominal cancer)
6) Inspection of precordium
- Spider naevi
- Gyanecomastia
- Axillary hair loss
7) Inspection of abdomen
- Ask patient to cough and to take a deep breath in and out (observe for masses)
- Scars
- Scratch marks
- Ascites
- Sister Mary Joseph’s nodule (widespread abdominal cancer)
- Cullen’s / Grey-Turner’s signs (pancreatitis)
- Distended veins
- Striae
3. 8) Palpation of abdomen
- Kneel down and look at patients face while you palapate
- Begin away from site of pain
- Palpate superficially in abdominal quadrants
- Palpate deeper in abdominal quadrants
- Feel for masses and tenderness and observe for guarding
- Abdominal aortic aneurysm
- Rovsing’s sign if appendicitis suspected
8) Examine the liver and gallbladder
- Inspect for fullness in right hypochondrium
- Palpate
- Place side of index finger on patient’s abdomen and ask them to breath in and out
- Move hand upwards towards ribs and note if liver can be felt (begin in right lower
quadrant)
- Observe for Murphy’s sign (acute cholecystitis)
- Percuss to identify liver margins
9) Examine the spleen
- Palpate
- Place side of index finger on patient’s abdomen and ask them to breath in and out
- Move diagonally towards left upper quadrant and note if spleen can be felt (begin in
right lower quadrant)
- Percuss to identify splenomegaly
10) Bimanual palpation of kidneys
11) Percussion of abdomen
- Begin percussing in centre of abdomen, moving peripherally, away from you to test
for dullness
- If dullness detected ask patient to role towards you, and percuss again after 30
seconds to a minute, testing for shifting dullness (ascites)
- Fluid thrill
- Percuss for bladder
12) Auscultation of abdomen
- Listen for bowel sounds
- Absent (e.g. ileus, peritonitis)
- Tinkling (bowel obstruction)
13) Examination of back
- Sacral oedema
- Auscultate for renal bruits
14) Observe for peripheral oedema
15) Further tests
- Examine external genitalia
- Digital rectal examination
- Urinalysis
- Examination of hernial orifices
- Pregnancy test in women of child-bearing age
4. Cardiovascular Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g GTN spray, ECG pads, oxygen)
- General inspection of patient:
- General comfort
- Are they sitting upright?
- Features of acute MI (e.g. sweating, pallor)
- Syndromic appearance (Marfan’s, Down’s, Turner’s, ankylosing spondylitis)
2) Inspection of hands and arms
- Inspect nails for:
- Clubbing
- Koilonychia (iron deficiency anaemia)
- Splinter haemorrhages (infective endocarditis)
- Inspect fingers for:
- Capillary refill time
- Peripheral cyanosis
- Osler’s nodes (infective endocarditis)
- Inspect palms for:
- Janeway lesions (infective endocarditis)
- Xanthomata
3) Palpation of hands and arms
- Radial pulse (rate, rhythm, character)
- Radio-radial delay (aortic dissection) and radio-femoral delay (coarctation of the
aorta)
- Collapsing pulse (aortic regurgitation)
- Slow-rising pulse (aortic stenosis)
- Bounding pulse (aortic regurgitation)
- Bisferiens pulse (mixed aortic stenosis and regurgitation)
- Pulsus alternans (severe left ventricular failure)
- Blood pressure
4) Inspection of head and neck
- Mitral facies (mitral stenosis)
- Conjunctival pallor
- Xanthalesma
- Corneal arcus
- Central cyanosis (look under the tongue)
- Poor dental hygiene (infective endocarditis)
- High arched palate (Marfan’s syndrome)
- Jugular venous pressure (height and waveform)
5) Palpation of head and neck
- Carotid pulse
6) Inspection of precordium
- Scars (e.g. thoracotomy, pacemaker, left axilla)
- Deformities (pectus excavatum, pectus carinatum)
7) Palpation of precordium
- Apex beat
- Heaves and thrills
- Feel for pulsating liver (tricuspid regurgitation)
8) Auscultation of heart valves
5. - Mitral valve (over the apex – 5th
intercostal space in mid-clavicular line)
- Listen with bell and diaphragm
- Role patient onto left side and listen with bell (mitral stenosis)
- Listen to axilla with bell (mitral regurgitation)
- Tricuspid valve (left inferior parasternal edge)
- Pulmonary valve (left parasternal edge in 2nd
intercostal space)
- Listen with diaphragm
- Aortic valve (right parasternal edge in 2nd
intercostal space)
- Listen with diaphragm
9) Sit patient up
- Auscultate over tricuspid and aortic areas at end expiration (aortic regurgitation)
- Auscultate over carotid arteries (aortic stenosis)
- Inspect back for scars and sacral oedema
- Percuss back for pleural effusion (cardiac failure, CABG)
- Auscultate over lung bases (pulmonary oedema)
- Observe for peripheral oedema
10) Further tests
- Blood pressure
- ECG
- Urinalysis (hypertensive nephropathy)
- Fundoscopy (hypertensive retinopathy, Roth spots)
- Peripheral vascular examination
6. Respiratory System Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g inhalers, oxygen)
- General inspection of patient:
- General comfort
- Respiratory distress / use of accessory muscles / breathing through pursed lips
- Cyanosis
- Evidence of long-term steroid therapy (i.e. Cushingoid appearance)
2) Inspection of hands and arms
- Clubbing
- Hypertrophic pulmonary osteoarthropathy
- Peripheral cyanosis
- Capillary refill
- Tar staining
- Dupytren’s contracture
- Wasting of small muscles of the hand (Pancoast tumour)
- Carbon dioxide retention flap / salbutamol tremor
3) Palpation of hands and arms
- Radial pulse and respiratory rate
4) Inspection of head and neck
- Conjunctival pallor
- Horner’s syndrome (Pancoast tumour)
- Plethora (polycythaemia)
- Central cyanosis (look under the tongue)
- Jugular venous pressure (height and waveform)
- Phrenic crush scar
5) Palpation of head and neck
- Feel for tracheal deviation
- Cricosternal distance
- Tracheal tug
- Cervical lymph nodes
6) Inspection of precordium
- Scars (e.g. thoracotomy)
- Deformities (barrel chest, kyphoscoliosis, pectus excavatum, pectus carinatum)
- Symmetry of expansion
- Dilated veins
- Intercostal recession
- Accessory muscle use
- Radiotherapy tattoo
7) Palpation of precordium
- Chest expansion
- Tactile vocal fremitus
- Apex beat
8) Percussion of precordium
- Begin over clavicles and move down over the lung fields, comparing side to side
- Percuss the axillae
9) Auscultation of precordium
- Auscultate over lung fields comparing sides
7. - Listen for vesicular or bronchial breath sounds
- Listen for added sounds
- Musical (wheeze, stridor)
- Non-musical (early inspiratory / late inspiratory / expiratory crackles, pleural rub)
10) Inspection of back
- Scars
11) Palpation of back
- Chest expansion
- Tactile vocal fremitus
- Sacral oedema
12) Percussion of back
13) Auscultation of back
14) Observe for peripheral oedema
15) Further tests
- Blood pressure (pulsus paradoxicus)
- Sputum analysis
- Peak flow rate and spirometry
- Oxygen saturation
8. Peripheral Vascular Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g GTN spray, ECG pads, oxygen)
- General inspection of patient:
- General comfort
- Pallor
- Amputations
2) Inspection of hands and arms
- Tar staining
- Capillary refill
- Pallor
- Hair loss
- Atrophic nail changes
- Xanthomata
3) Palpation of hands and arms
- Radial pulse (rate, rhythm, character)
- Radio-radial delay (aortic dissection) and radio-femoral delay (coarctation of the
aorta)
- Ulnar pulse
- Brachial pulse
- Blood pressure
4) Inspection of head and neck
- Xanthalesma
- Corneal arcus
- Central cyanosis (look under the tongue)
5) Palpation of head and neck
- Carotid pulse (also auscultate for bruits)
6) Examination of precordium
- Scars (e.g. thoracotomy, pacemaker, left axilla)
- Auscultation of heart valves
7) Examination of abdomen
- Observe for pulsatility
- Palpate for abdominal aortic aneurysm
- Auscultate for renal and aortic bruits
8) Examination of femoral pulse
- Palpate
- Auscultate for bruits
9) Examination of lower limbs
- Inspection
- Pallor
- Ulcers (especially on heels) and gangrene (between toes)
- Scars
- Atrophic change
- Nail changes
- Hair loss
- Achilles tendon xanthomata
- Palpation
- Feel temperature
9. - Pulses – Popliteal, posterior tibial and dorsalis pedis
- Buerger’s test – Elevate the legs to 45˚ for 1 minute. Normally they should retain
colour, but in peripheral vascular disease they become pale. Then swing the patient’s
legs off the side of the bed while they sit upright. In peripheral vascular disease they
will become red.
- Venous guttering – Inspect for this during Buerger’s test
10) Further tests
- Blood pressure
- Cardiovascular examination
- Ankle brachial pressure index
- Peripheral neurological examination
- Gait examination
- Ultrasound Doppler assessment
10. Cranial Nerve Examination
1) General
- Introduce self and gain consent
- Wash hands
- Look for medical equipment / therapies (e.g. walking aids)
- Ask if left or right handed
- General inspection of patient:
- Conscious level of patient
- Abnormal posture / movements
2) Inspection of face
- General look for signs of cranial nerve palsies (e.g. facial paresis, Horner’s
syndrome)
3) I – Olfactory nerve
- Ask about recent changes in sense of taste or smell
4) II – Optic nerve
- Acuity
- Ask patient to read something (e.g. name badge), while covering one eye, and
repeat with other eye (this will tell you if there is monocular blindness or a glass eye
for example)
- Colour
- Ask patient to identify the colour of a particular object
- Visual fields
- Assess vision in the nasal and temporal upper and lower fields of each eye
separately
- Test for neglect and inattention - Place your hands in the patient’s temporal fields
and ask them to point to the hand that you move (move each hand separately and
then both at the same time)
- Accommodation
- Pupilllary reflexes
- Direct and consensual reflexes
- Afferent pupillary defect
- Fundoscopy
5) Eye movements (III, IV and VI – Oculomotor, trochlear and abducens nerves)
- Ask patient to follow your finger in an “H” pattern, while keeping their head still
- Hold your finger still for a second as it reaches the most lateral, highest and lowest
points, to look for nystagmus
- Ptosis
- Assess saccadic eye movements
6) V – Trigeminal nerve
- Assess sensation of face on the forehead, maxilla and mandible (to assess the three
trigeminal branches)
- Motor
- Ask patient to clench jaw and feel for tension over the masseters and temporalis
muscles
- Ask patient to hold jaw open against resistance
7) VII – Facial nerve
- Ask about hyperacousis
- Assess movements of facial muscles
- Ask patient to raise eye brows and hold them there against resistance
- Ask patient to scrunch up eyes, and not let you open them
- Ask patient to blow out cheeks and not let you push the air out
- Ask patient to smile / show teeth
11. 8) VIII – Vestibulocochlear nerve
- Ask about recent changes in balance and tinnitus
- Assess hearing – Whisper a number in each ear while rustling your fingers near the
contralateral ear, and ask patient to repeat
- Rinne’s and Weber’s tests
9) IX and X – Glossopharyngeal and vagus nerves
- Look at position of uvula (deviates away from the side of a lesion)
- Ask patient to say “ah” and assess palatal elevation
- Cough
11) XI – Accessory nerve
- Trapezius – Ask patient to shrug shoulders against pressure
- Sternocleidomastoid – Ask patient to turn head to contralateral side against
resistance
12) XII – Hypoglossal nerve
- Tongue fasciculations
- Tongue wasting
- Assess tongue movements (tongue deviates towards the side of a lesion)
13) Further tests
- Lower limb neurological examination
- Upper limb neurological examination
- Gait examination
- Formal test of taste and smell (I)
- Corneal reflex and jaw jerk (V)
- Gag reflex (IX)
- Snellen chart and ischihara chart (II)
N.B. You may chose to mention these tests as you examine their respective nerves
12. Upper Limb Nervous System Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g. walking aids)
- Ask if left or right handed
- General inspection of patient:
- General comfort
- Abnormal posture / movements
- Muscle wasting
- Look at the cervical spine for scars
2) Inspection of upper limbs
- Wasting
- Abnormal posture
- Abnormal movements
- Fasciculations (use pen torch)
3) Assessment of tone
- Ask patient to relax arm, and allow you to move arm passively at shoulder, elbow,
wrist and fingers
- Assess for spastic catch
- Assess for clasp-knife rigidity
- Note led-pipe or cog-wheel rigidity
4) Assessment of power
- Shoulder abduction (C5)
- Shoulder adduction (C5 / 6 / 7)
- Elbow flexion (C5 / 6)
- Elbow extension (C7)
- Wrist flexion (C8)
- Wrist extension (C8)
- Finger flexion (C8)
- Finger abduction (T1)
- Finger adduction (T1)
- Thumb abduction (C8)
5) Reflexes
- Biceps (C5 / 6)
- Triceps (C6 / 7)
- Supinator (C5 / 6)
- Finger flexion (C7 / 8)
- Hoffman’s reflex (C7 / 8)
6) Coordination
- Pronator drift – Ask patient to extend arms in front of them in supination, and to close
their eyes. A positive result occurs when the arm falls downwards and pronates
(cerebral damage). In cerebellar lesions, the arms may rise)
- Assess for dysdiadochokinesis
- Assess for finger-to-nose coordination, and intention tremor
7) Sensation
- Light touch
- Demonstrate over sternum
- Shoulder tip (C4)
- Lateral upper arm (C5)
- Lateral / anterior forearm (C6)
- Middle finger (C7)
13. - Medial forearm (C8)
- Medial arm, above the elbow (T1)
- Medial upper arm (T2)
- Assess distal vs. proximal and left vs. right
- Pin-prick sensation (assess through dermatomes as above)
- Proprioception – Flex and extend middle finger at distal interphalangeal joint with
patient’s eyes closed, and ask patient to say if finger moves up or down.
- Vibration – Use 128 Hz tuning fork on bony prominences, beginning distally and
moving proximally until vibration is perceived
8) Further tests
- Lower limb neurological examination
- Cranial nerves examination
- Gait examination
14. Lower Limb Nervous System Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g. walking aids)
- Ask if left or right handed
- General inspection of patient:
- General comfort
- Abnormal posture / movements
- Muscle wasting
2) Inspection of lower limbs
- Wasting
- Abnormal posture
- Abnormal movements
- Fasciculations (use pen torch)
3) Assessment of tone
- Ask patient to relax leg, and allow you to roll it from side to side, watching for ankle
lag (there should be some ankle lag – if no lag there is hypertonicity)
- Raise leg off the bed passively (increased tone is indicated by the foot coming off the
bed)
- Clonus
4) Assessment of power
- Hip flexion (L1 /2)
- Hip extension (L5 / S1)
- Hip abduction (L2 / 3)
- Hip adduction (L2 / 3)
- Knee flexion (L5 / S1)
- Knee extension (L3 / 4)
- Ankle dorsiflexion (L4 / 5)
- Ankle plantar flexion (S1 / 2)
- Big toe flexion ( S1 / 2)
5) Reflexes
- Knee (L3 / 4)
- Ankle (S1 / 2)
- Plantar (S1)
6) Coordination
- Ask patient to slide heel down contralateral shin repeatedly as fast as possible
7) Sensation
- Light touch
- Demonstrate over sternum
- Anterior hip (Jeans pocket – L1)
- Upper anterolateral thigh (L2)
- Anteromedial knee (L3)
- Anteromedial shin (L4)
- Lateral lower limb and big toe (L5)
- Sole of foot (S1)
- Back of thigh (S2)
- Compare distal vs. proximal and right vs. left
- Pin-prick sensation (assess through dermatomes as above)
- Proprioception – Flex and extend big toe at interphalangeal joint with patient’s eyes
closed, and ask patient to say if toe moves up or down.
15. - Vibration – Use 128 Hz tuning fork on bony prominences, beginning distally and
moving proximally until vibration is perceived
8) Stand patient up
- Gait
- Inspect lumbar spine (scars)
- Romberg’s test
- Ask patient to stand with feet together
- If patient loses balance with eyes open there is cerebellar ataxia
- Ask patient to close their eyes – If they lose balance with eyes closed there is
proprioceptive ataxia
9) Further tests
- Upper limb neurological examination
- Cranial nerves examination
16. GALS Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g walking aids)
2) Screening questions
- “Do you have any pain in your muscles, joints or back?”
- “Can you dress yourself without difficulty?”
- “Can you walk up and down stairs without difficulty?”
3) Observe gait
- Comment on symmetry, stride length, and ability to turn
4) Stand patient up
- Inspect from behind
- Varus / valgus deformity of the legs
- Scoliosis
- Symmetry of muscle bulk
- Symmetry of iliac crests
- Symmetry of shoulders
- Popliteal swelling
- Palpate for trigger point tenderness (apply pressure over mid supraspinatus)
- Inspect from side
- Kyphosis
- Assess movement in lumbar region (place fingers on lumbar spine and ask patient
to bend forwards – normally your fingers should move apart)
- Arches of feet
- Inspect from front
- Quadriceps wasting
5) Sit patient down
- Observe active movements
- Neck rotation and lateral flexion
- Thoracic rotation
- “Hands behind head”
- “Hands in small of back”
- Prayer sign (wrist extension)
- Elbow flexion and extension
- Rest hands on pillow
- Inspect palms for wasting / deformities
- Make fist and squeeze finger nails into palms (look for impressions of the nails in the
palm to assess power grip strength)
- Pronate arms (active)
- Inspect nails and joints
-Inspect for dorsal wasting or deformity
- Metacarpal squeeze
6) Lie patient down
- Inspect soles of feet for calluses and ulcers
- Inspect feet for deformities or wasting
- Ask patient to dorsiflex and plantarflex toes
- Metatarsal squeeze
- Knee effusions
- Bulge test
- Patellar tap
- Passive movement
- Knee flexion (feel for crepitus)
18. Hip Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g. walking aids)
- Ask which hip is painful
2) Inspection of hip (patient standing up)
- Obvious deformity or muscle wasting
- Scars
- Leg-length discrepancy
- Skin changes (erythema, abscesses, sinuses)
- Asymmetry of pelvic brim and dimples of Venus (spinal scoliosis or leg-length
discrepancy)
3) Gait
- Antalgic gait
- Trendelenberg
- Leg-length discrepancy (high-stepping or swinging)
4) Trendelenberg test
- Ask patient to rest their arms on yours (while standing)
- Ask them to lift up the leg on the same side as the painful hip for 30 seconds (this
tests the contralateral adductor mechanism
- Feel for loss of balance indicated by patient using your hands to correct themselves
- Repeat with other leg
5) Lie patient on couch
- Inspection
- Hip and groin swellings (hernia, lymphadenopathy, saphenous varix, effusion)
- Obvious fixed flexion
6) Palpation of hip
- Palpate anterior hip for lumps and tenderness
- Palpate greater trochanter for trochanteric bursitis
7) Leg-length difference
- Make an approximate judgement by aligning the medial malleoli andlooking for
discrepancy
- Measure real and apparent discrepancy if appropriate
- Real – Measure from greater trochanters on each leg to ipsilateral lateral malleolus
- Apparent – Measure from umbilicus to lateral malleolus
8) Active and passive movements
- Assess active flexion, extension, abduction and adduction
Ask patient to move in each direction as far as possible then passively move the leg
to its limits
- Passively assess internal and external rotation of hip (with hips at 90˚ flexion)
9) Thomas’s test
- Place hand on patient’s lumbar spine
- Passively flex the normal hip, and ask patient to pull their knee up towards them as
far as possible with their hands
- Look for fixed flexion of the contralateral leg which may be unmasked
- Repeat with other leg
- Avoid this test if there is a hip replacement as this may cause dislocation
10) Further tests
19. - Full neurological examination of the lower limbs
- Full vascular examination of the lower limbs
- Plain radiograph of the hips
- Examination of the spine and knee
- Full blood count and inflammatory markers
20. Knee Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies (e.g. walking aids)
- Ask about knee locking, giving way and pain
2) Inspection of knee (patient standing up)
- Varus / valgus deformity
- Swelling / redness
- Popliteal swelling (Baker’s cyst)
- Scars (midline scars suggests total knee replacement, lateral scars suggest an old
cartilage repair or arthroscopic surgery)
3) Gait
- Antalgic gait
- Foot drop (peroneal nerve damage at head of fibula)
4) Sit patient on side of couch
- Assess extensor apparatus of leg (ask patient to straighten their leg)
- Inspect hands for Heberden’s and Bouchard’s nodes
5) Lie patient on couch
- Inspect knee for any swellings that may be revealed
- Look for quadriceps wasting
6) Palpation of knee
- Pain
- Feel along tibio-femoral joint line
- Feel around patella
- Temperature
- Effusions
- Patella tap (place fingers either side of patella and tap down on patella with other
hand)
- Bulge test (Milk fluid out of medial compartment and try and push it back by sliding
your hand down the lateral compartment)
7) Movements
- Active flexion and extension of knee – Observe for restricted movement and for
displacement of patella)
- Passive flexion and extension of knee – Feel for crepitus
- Patella apprehension test – Move patella around and observe patient’s face for pain
- Straight leg raise (assessment of extensor apparatus)
8) Ligaments
- Assess for subluxation and loss of a sharp end-point
- Anterior cruciate ligament
- Anterior draw test (flex knee to 90˚, sit on patient’s feet and pull tibia forwards)
- Lachman’s test (flex knee to 30˚ and try to move tibia forward – it is easiest if you
place your knee under the patient’s knee)
- Posterior cruciate ligament
- Posterior sag test (bend knee to 90˚ and inspect from sides for sagging)
- Collateral ligaments
- Hold the outstretched leg (slightly flexed) resting on your pelvis, and apply varus
and valgus deformity to the knee
9) Menisci
- McMurray’s test
21. - Fully flex knee and internally rotate. As you extend the knee in external rotation pain
suggests meniscal tear
- Repeat in internal rotation
- N.B Do not perform in OSCE as this test is painful for patient if positive
10) Further tests
- Full neurological examination of the lower limbs
- Full vascular examination of the lower limbs
- Plain radiograph of the knees
- Examination of the hip and of the ankle
- Full blood count and inflammatory markers
22. Ankle Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed (up to above knees)
- Look for medical equipment / therapies (e.g. walking aids)
- Ask if patient is able to weight bear
- Inspect shoes for abnormal / asymmetrical wearing
2) Gait
- Antalgic gait
- Foot drop (peroneal nerve damage at head of fibula)
- Look for deformity on weight-bearing
- Assess ability to weight-bear on affected side
3) Inspection of ankle / foot
- Patient should have their feet up or should be sitting on the side of the couch with
their feet overhanging
- Symmetry
- Deformity / swellings
- Nail changes
- Skin changes (psoriasis)
- Toe alignment (hallux valgus, clawing of toes)
- Calluses (above and below metatarsophalangeal joints and on plantar surface)
- With patient standing (weight-bearing)
- Toe alignment
- Arch position (if arch is dropped in a normal individual, it should reappear when
standing on tip-toes)
- Achilles swelling
- Alignment of hindfoot (varus / valgus deformity)
4) Palpation of ankle / foot
- Assess temperature over ankle and forefoot
- Metatarsal squeeze (watch patient’s face for discomfort)
- Palpate malleoli and the bones of the foot for tenderness
5) Assess ankle movements
- Active and passive movements
- Subtalar joint – Inversion and eversion
- Ankle joint – Dorsiflexion and plantar flexion
- Big toe - Dorsiflexion and plantar flexion
- Mid-tarsal joints – Fix heel with one hand and passively invert and evert the forefoot
6) Brief neurovascular assessment
- Strength of peripheral pulses
- Capillary refill
- Light touch / pinprick
- Proprioception
- Vibration
7) Further tests
- Full neurological examination of the foot
- Full vascular examination of the foot
- Plain radiograph of the ankles / feet
- Examination of the knee
- Full blood count and inflammatory markers
23. Hand Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed (to above the elbows)
- Look for medical equipment / therapies (e.g. walking aids)
2) Inspection of elbows
- Psoriatic skin lesions
- Rheumatoid nodules
- Scars
3) Inspection of hands
- Ask patient to rest hands palm down on a pillow
- Inspect dorsum
- Skin (rashes, Gottron’s patches, nodules, Raynaud’s phenomenon, sclerodactyly,
scars, skin atrophy)
- Nails (pitting, onycholysis, splinter haemorrhages, clubbing)
- Muscles (swellings, wasting)
- Joints (swellings, subluxation / deviation of wrist, swan-neck / Boutoniere’s
deformities, Heberden’s / Bouchard’s nodes, Z deformity of thumb)
- Inspect palm
- Skin (palmar erythema, pallor, cyanosis)
- Muscles (wasting)
4) Palpation of hands
- Temperature
- Metacarpal squeeze
- Depress distal ulna and radius (examining for distal radio-ulnar joint synovitis)
- Dupytren’s contracture
- Wrist joint line for tenderness
- Metacarpophalangeal joints (this is most easily performed if the patient makes a fist)
- Interphalangeal joints (bimanual palpation)
5) Movements
- Ask the patient to perform the following movements in this sequence and observe for
range of movement:
- Make a fist
- Pronate wrist
- Extend little finger (extensor digiti minimi is usually the first tendon to rupture in
rheumatoid arthritis)
- Extend all fingers
- Prayer sign (wrist extension)
- Wrist flexion (hands back-to-back)
- Phalen’s test if carpal tunnel syndrome suspected
6) Assess power
- Wrist extension (radial nerve)
- Thumb abduction (median nerve)
- Finger abduction (ulnar nerve)
7) Assess function
- Pinch grip
- Opposition (touch thumb to each finger)
- Power grip (ask patient to squeeze your fingers)
- Froment’s test (for ulnar nerve palsy)
- Ask patient to write something / undo a button
8) Neurovascular assessment
24. - Light touch in autonomous areas
- Median nerve – Pulp of index finger
- Ulna nerve – Pulp of 5th
finger
- Radial nerve – 1st
dorsal interosseous space
- Also test light touch on the middle finger (this tests the C7 dermatome – by testing
the autonomous areas you have already tested the C6 and C8 dermatomes)
- Test for peripheral neuropathy by comparing light touch distally with proximally
- Capillary refill
- Radial and ulnar pulses
9) Further tests
- Full neurological examination of the upper limbs
- Full vascular examination of the upper limbs
- Plain radiograph of the hands
25. Shoulder Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies
- Ask which shoulder is painful
2) Inspection of shoulder (patient sitting down)
- Obvious deformity or muscle wasting
- Scars
- Skin changes (erythema, abscesses, sinuses)
- Asymmetry
3) Palpation of shoulder
- Begin at the sternovlavicular joint, work your way across the clavicle to the
acromioclavicular joint before continuing to palpate over the acromium and spine of
scapula
- Palpate the cervical vertebrae (stand behind patient)
4) Assess neck movements
- Flexion
- Extension
- Lateral flexion
- Rotation
5) Assess shoulder movements (patient standing up)
- Ask patient to perform each movement actively, before passively moving the arm as
far as possible
- Shoulder abduction and adduction (inspect from in front to observe for pain, and
behind to assess movement of the scapulae)
- When testing adduction perform the scarf test (forced adduction of the shoulder
testing for acromioclavicular joint disease)
- Observe for painful arc syndrome (due to impingement – inflammation of
supraspinatus)
- Shoulder flexion and extension
- Rotation
- Internal rotation – Ask patient to place hands in the small of their back, and slide
them up the back as far as possible
- External rotation – Ask patient to rotate their arms out, keeping their elbows in by
their side
- Also assess power of external rotation (To test for an infraspinatus or teres
minor tear)
6) Special tests
- Test for infraspinatus or teres minor tear (already performed by assessing power of
external rotation)
- Test for subscapularis tear – Ask patient to place hands in small of back and push out
against your hands
- Test for supraspinatus tear
- Ask patient to put their arms out straight in front of them, slightly abducted, with
thumbs up
- Ask patient to push arms while you try to hold them down
- Repeat with thumbs pointing down (this tests a different part of the tendon for
impingement)
- Apprehension test (for instability)
- Passively put the patient into 90˚ elbow flexion and 90˚ shoulder abduction
- Carefully push the elbow back and observe for apprehension or ask if patient feels
as thought the shoulder is unstable
26. - Applying pressure over the anterior humerus should abolish instability
- This test can be performed with the patient standing up or lying down
- N.B There is a multitude of eponymous tests for shoulder disease, but the tests listed above
cover all of the conditions that are likely to come up in an OSCE setting
7) Further tests
- Full neurological examination of the upper limbs
- Full vascular examination of the upper limbs
- Plain radiograph of the shoulders
- Examination of the cervical spine and elbow
27. Elbow Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies
2) Inspection of elbow
- Scars
- Rashes / psoriatic plaques
- Muscle wasting
- Elbow extended
- Fixed flexion
- Varus / valgus deformity
- Elbow flexed
- Swellings (e.g. olecranon bursitis, cysts, rheumatoid nodules)
3) Palpation of elbow
- Palpate the olecranon, epidcondyles (medial for golfer’s elbow and lateral for tennis
elbow) and cubital fossa for tenderness
- Characterise any mass
- Feel temperature
- Palpate joint line with elbow flexed to 90˚ for tenderness and swelling
4) Assess elbow movements
- Active flexion and extension
- Passive flexion and extension – Determine range of movement and feel for crepitus
- Also assess pronation and supination
- Assess power of movements
- Test for varus / valgus instability
- Function – Ask patient to put hands behind head
5) Neurological examination of hand
- Motor
- Median nerve – Thumb abduction
- Radial nerve – Wrist extension
- Ulnar nerve – Finger abduction
- Sensory
- Median nerve – Pulp of index finger
- Radial nerve – 1st
dorsal interosseous space
- Ulnar nerve - Pulp of 5th
finger
6) Further tests
- Full neurological examination of the upper limbs
- Full vascular examination of the upper limbs
- Plain radiograph of the elbow
- Examination of the shoulder and hand
28. Spine Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies
2) Inspection of spine (patient standing up)
- From behind:
- Pelvic and shoulder symmetry (use wooden blocks if there is a leg-length
discrepancy)
- Palpate the pelvic brim to check for symmetry
- Scoliosis
- Gibbus (dorsal spines abnormally prominent)
- From side:
- Kyphosis
- Increased lumbar lordosis
3) Lumbar movements
- Flexion (ask patient to touch toes keeping their legs straight)
- Extension (ask patient to lean back as far as possible)
- Lateral flexion (ask patient to slide their hands down the outside of their leg while
keeping it straight)
- Observe for restricted movement and loss of symmetry
- Test for facet joint disease – Ask patient to extend their back as far as possible and to
rotate (pain suggests facet joint pathology)
4) Ankylosing spondylitis tests
- Chest expansion – Measure with a tape measure (should be >5cm)
- Schöber’s test – Draw a horizontal line 10cm above and one 5cm below the dimples
of Venus (the distance between these lines should increase to >20cm during lumbar
flexion – in ankylosing spondylitis the distance will not increase to >20cm)
- Distance of tragus to wall when patient standing straight with their back to the wall
(useful for monitoring)
N.B. You will probably not be expected to perform these in an OSCE but it is useful to
know about them if you suspect ankylosing spondylitis
5) Cervical and thoracic movements (patient sitting on edge of bed)
- Thoracic rotation (ask patient to fold their arms and twist around)
- Cervical movements
- Flexion (ask patient to touch chin to chest)
- Extension (ask patient to look as far back as possible)
- Lateral flexion (ask patient to touch their ear to the shoulder keeping the shoulder
still)
- Rotation (ask patient to look over the left and right shoulder)
- Perform these movements passively if active movements are restricted
6) Lie patient on back
- Straight leg raise (tests for dural tension)
- Sciatic stretch test (perform a straight leg raise and dorsiflex the ankle – exacerbation
of pain suggests disc prolapse)
- Sacroiliac springing for sacroiliac joint disease (flex hip to 90˚ and apply downwards
pressure on the knee – if any pain caused is improved by the patient placing their
hand in the lumbar lordosis, it suggests that the pain is in the hip rather than the
sacroiliac joint)
7) Lie patient on front
- Femoral stretch test for dural tension (positive if flexing the knee fully reproduces
pain)
- Palpation of vertebrae
29. - Feel the interspinous spaces and laterally to each vertebrae for local tenderness
8) Neurological tests
- Assess upper and lower limb power, reflexes and sensation
9) Further tests
- Full neurological examination of the upper limbs
- Full neurological examination of lower limbs
- Assess perianal sensation (if cauda equina syndrome suspected)
30. Breast Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Brief history
- Ask which side the problem is
- Presenting complaint
- Therapies received
2) Position 1 – Patient sitting on side of bed
- Inspect with:
- Patient’s arms by their sides
- Patient’s arms behind their head (tenses skin)
- Patient’s hands on their hips (tenses pectoralis major)
(these manoeuvres test for T4 disease – invasion of chest wall / skin)
- Obvious masses
- Scars
- Radiotherapy tattoos
- Skin changes
- Peau d’orange
- Dimpling
- Nipple retraction
- Paget’s disease
3) Position 2 – Patient lying flat
- Inspect inframammary folds
- Palpate normal breast followed by abnormal breast
- Palpate all quadrants, nipple and axillary tail of each breast
- Describe any masses
- Position, size, shape, mobility, number, tenderness, consistency
- Palpate axillary and supraclavicular lymph nodes
- Ask patient about discharge, and ask them to express some if possible
4) Palpate for hepatomegaly
5) Axillary examination
- Palpate for axillary, supraclavicular and infraclavicular lymph nodes
6) Further tests
- Auscultate lungs
- Ultrasound / mammogram
- Core biopsy
31. Thyroid Examination
1) General
- Introduce self and gain consent
- Wash hands
- Ensure patient is adequately exposed
- Look for medical equipment / therapies
- General inspection of patient:
- Weight gain / loss
- Anxious state
- Note hoarseness of the voice
2) Examination of hands and arms
- Tremor (assess by asking patient to hold a piece of paper)
- Sweaty / dry palms
- Warm / cold skin
- Palmar erythema
- Thyroid acropachy
- Carpal tunnel syndrome (Tinel’s and Phalen’s tests) – Associated with
hypothyroidism
- Radial pulse – Rate and rhythm
- Arm reflexes – Brisk in hyperthyroidism
3) Examination of eyes
- Lid retraction
- Lid lag
- Exophthalmos (Grave’s disease) – Look from behind patient
- Ophthalmoplegia (ask patient to follow your finger and ask about diplopia)
- Periorbital oedema (usually non-pitting)
- Chemosis (redness and watering of eye)
4) Inspection of neck
- Scars
- Masses / goitre
5) Examination of the thyroid gland and cervical lymph nodes
- Swallow tests – Ask patient to swallow water and observe for movement of any
masses
- Tongue protrusion – Thyroglossal cyst moves on protrusion
- Palpate thyroid (standing behind patient) – Assess size, texture, smoothness and
mobility (including when swallowing)
- Palpate cervical lymph nodes
- Percuss over sternum – Retrosternal goitre
- Auscultate for throid bruit (Grave’s disease)
6) Pemberton’s sign and proximal myopathy
- Ask patient to hold their arms as high above their head as possible
- Pemberton’s sign = flushing, distension of neck veins, raised JVP and inspiratory
stridor due to thoracic inlet obstruction (e.g. due to goitre)
7) Examination of legs
- Pretibial myxoedema
- Peripheral oedema due to congestive cardiac failure
- Delayed relaxation of ankle reflex in hypothyroidism
