STEP-BY-STEP

INTERACTIVE MANUAL

OF

PHYSICAL EXAMINATION

Dr. N. T. A. AZEEZ

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 PREFACE

There are many books written on physical examination for students and practicing doctors. There

is a dearth of textbooks on general physical examination in the developing nations despite the

peculiarities of the patients and the practice. The beauty of this manual in your hand is its

interactive nature. It is simple, straightforward, imaginative and comprehensive.

This booklet is useful to medical students and postgraduate doctors especially those preparing for

specialty examination in Internal Medicine and its sub-specialties. The simplicity is second to

none. This is a well-thought effort at reaching you. So, I had you in mind when writing this

booklet. It is from me to you, with love!

The material has been divided into various systems and each system is thoroughly covered. Each

section is written with the assumption that you already have a background knowledge of the

basics of physical examination of various systems. Therefore, this book was not written to

condemn previously written books but to bring the best out of what you have read with a special

focus on the examiners’ expectation. It is aimed as a last-minute revision tool before you enter

the examination hall. Good luck!

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 ACKNOWLEDGEMENT

I acknowledge the Giver of knowledge, my Creator, the God of heaven and earth. He has given

me enablement and vision to be useful to my world. I am grateful to my teachers both at

undergraduate and postgraduate levels. I appreciate all my senior colleagues who showed me the

beautiful path of Human Medicine. I give kudos to my junior colleagues who gave me the

opportunity to impart knowledge. Friends and well-wishers are highly appreciated.

The Department of Medicine, University College Hospital (UCH) Ibadan, is the best place to be.

It is the epicenter of knowledge as far as medical practice in West Africa is concerned. It gave

birth to them all, literally speaking.

All my teachers in Endocrinology, Metabolism and Diabetes Unit, Department of Medicine,

UCH Ibadan are worthy of special recognition. They taught me to fall in love with excellence. I

think you are legends. My other teachers in the Department have imparted into me greatly

beyond measure. Thank you for your cerebral contribution.

To all the Endocrinologists and Endocrinologists-in-training in West Africa, you have made the

right choice and it shall not be taken away from you. Dr. Martins Emuze deserves a special

mention for his painstaking editing. He is in love with his God, his wife and excellence.

Association of Resident Doctors (ARD) UCH is a conglomerate of lovers of excellence. I love

you all. I salute the house!

My darling wife, T.G. Azeez is the best. He who finds a wife finds a good thing and obtains

favour from the Lord. We also have Joy (our daughter) in our household. Glory to the Almighty.

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TABLE OF CONTENTS

PREFACE ………………………………………………………………………………2

ACKNOWLEDGEMENT………………………………………………………………3

CHAPTER 1 (CADIOVASCULAR EXAMINATION)………………………………..5

CHAPTE 2 (ABDOMINAL EXAMINATION)………………………………………..19

CHAPTER 3 (CHEST EXAMINATION)……………………………………………...30

CHAPTER 4 (NEUROLOGICAL EXAMINATION)……………………………….…37

CHAPTER 5 (THYROID EXAMINATION) …………………………………………..46

CHAPTER 6 (GENERAL PHYSICAL EXAMINATION) ………………………… …53

CHAPTER 7 (JOINT EXAMINATION) …………………………………………… …57

CHAPTER 8 (SKIN EXAMINATION)…………………………………………………62

REFERENCES …………………………………………………………………………..66

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 CHAPTER ONE

CARDIOVASCULAR EXAMINATION

INTRODUCTION

 Greet the examiner

 Move straight to the right side of the patient. Even if you are left-handed, endeavour to

practise with the right side because you don’t want to start unnecessary argument with the

examiner at this stage.

 Greet the patient.

 Introduce yourself to the patient, allay his/her fears and obtain consent.

 Screen the patient or pretend as if you want to screen if patient is already screened.

 Apply your hand sanitizer. Endeavour to come with your own hand sanitizer.

 Ensure patient is adequately exposed

 Position the patient appropriately. Cardiac position i.e. 450 head up. The upper limbs are

by the side with palms facing upwards.

 Take a quick look around the patient’s bedside. Observe if there is oxygen cylinder (this

may suggest that he/she is/was in heart failure), intravenous fluid infusion (patients in

heart failure are usually not given intravenous fluids routinely).

 Take a quick look at the patient. Observe if he/she is dyspnoeic at rest. Observe if there is

a goitre.

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 Move to the foot of the bed and bend such that your eyes are at the level of the

precordium. Look if the apical impulse is visible and if it is displaced in relation to the

imaginary left mid-clavicular line.

 Move back to the right side of the patient.

EXAMINE THE PERIPHERAL PULSES

 Count the pulse rate using the radial artery for 15 seconds and multiply by 4. If the

rhythm is clearly irregular, count for 30 seconds and multiply by 2 (ideally, you should

count for one minute but you may not have the luxury of counting for 1 minute in a 6

minute exam).

 Note the volume of the pulse: small volume

normal volume

large volume

If it is a large volume pulse, check for collapsing pulse. If it is not a large volume pulse,

checking for collapsing pulse is not necessary. If you do this, your marks will go down.

 Note the rhythm of the pulse: regular

regular with occasional missed beats

regular with frequent missed beats

irregularly irregular

if the pulse is irregularly irregular, count the heart rate immediately and note the pulse

deficit. Pulse deficit greater than 20 beats per minute suggests atrial fibrillation.

 Check for arterial wall thickness

 Check for radio-radial delay, then radio-femoral delay.

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 Feel the brachial pulses bilaterally at the same time. Brachial artery is not centrally

placed in the cubital fossa but somewhat lies medially.

 Palpate the right carotid artery with your left thumb.

 Palpate the left carotid artery with your right thumb. Don’t palpate the two carotid

arteries simultaneously.

 Palpate the superficial temporal arteries bilaterally simultaneously.

 Palpate the femoral arteries bilaterally simultaneously.

 Use both hands to flex the right knee of the patient to 300 and palpate the right popliteal

artery. Then, use both hands to flex the left knee of the patient to 300 and palpate the left

popliteal artery.

 Palpate the right posterior tibial artery with your right fingers and the left posterior tibial

artery with your left fingers. To do this, you would need your forearms crossed. This method

is smoother than using your right fingers to palpate the right posterior tibial artery and left

fingers to palpate the left posterior artery. You may want to check this out right now!

 Palpate the dorsalis pedis arteries bilaterally simultaneously.

 Check for locomotor brachialis on the right using your pen torch. Then check on the left

also.

BLOOD PRESSURE MEASUREMENT

 Ask for a sphygmomanometer to do the blood pressure.

 If given a sphygmomanometer, apply the cuff to the right arm appropriately and check

the blood pressure properly. Don’t be too hasty and don’t be too sluggish at the same

time

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 JUGULAR VENOUS PULSATION

 Examine the jugular venous pulsation

 Turn the neck of the patient to about 450 to the left

 Hold your pen torch with your left hand at all times. The pen torch is

positioned superior and parallel to the sternocleidomastoid muscle.

 Rule of thumb: any pulsation in the right side of the neck along the

sternocleidomastoid muscle is the jugular venous pulsation until proven

otherwise. Yes, any pulsation!

 There are seven steps you must follow when examining the jugular venous pulsation.

1. Look at the uppermost part of the pulsation. It is usually double pulsation

(a and v waves are seen, the c wave is hardly seen).

2. Tell the patient to breath in deeply and hold the breath for a few seconds

while you normally observe a slight (unfortunately, it’s not as remarkable

as the books say!) fall in the height of the pulsation.

Tell the patient to resume his normal breathing (of course the patient

would have resumed his normal breathing by then but you must be seen to

have given the instruction).

3. Palpate the uppermost part of the pulsation with your index and middle

fingers. Now, there is an issue here to take note carefully-

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 The books say that if it is the internal jugular vein pulsation, it should not

be palpable ordinarily. The truth is when you palpate the jugular venous

pulsation, you will feel the pulsation of the carotid because it lies very

close to the internal jugular vein. However, even if you feel something, in

order to satisfy the examiner, IT IS NOT PALPABLE!

4. Compress the vein in between the heads of the sternocleidomastoid muscle

with your right thumb at the base of the neck. You expect a slight (again,

it’s not as remarkable as the books say!) rise in the height of the pulsation.

5. Ask if the patient feels pain in the abdomen. Avoid the area of the pain as

much as possible. Press the abdomen gently but deeply and hold it for a

few seconds. You expect a slight rise in the height of the jugular venous

pulsation.

6. Ask the patient to sit up, lift the patient’s right ear gently and look behind

the ear for any pulsation (if you could not appreciate the highest level of

the pulsation before now). This step hardly adds anything but you must

still do it. Why? Convention!

7. Ask the patient to go back to the cardiac position and measure the jugular

venous pressure. Note that you examine jugular venous pulsation but

measure the jugular venous pressure (a reason why you should avoid the

abbreviation JVP). Some people also struggle with the abbreviation ECG-

electrocardiogram or electrocardiograph? Any value above 3 cm (provided

the reference point is the manubriosternal angle) is considered elevated

jugular venous pressure.

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 Note that throughout the period of examination of the jugular venous pulsation, the left

hand remains still, shining the torch light at a position previously described. It is the right

hand that does the manouvres.

EXAMINE THE PRECORDIUM

 Proceed to the examination of the precordium

 You must bend and move close to the chest as if you want to enter the precordium. Then,

shine your pen torch. If you can see any cardiac impulse, the precordium is said to be

hyperactive, if you can’t see any impulse, the precordium is normoactive (please, not

hypoactive!).

 Place your whole hand flat over the precordium to have a general impression of the

cardiac activity. Then, locate the apex beat and count towards your right index finger

placed at the apex beat. Draw an imaginary line (mid-clavicular or anterior axillary line,

for example) to show the examiner your reference point for the displacement. The

examiner wants to see you do this. If it cannot be felt, ask the patient to roll to the left

side. In this case, you will only locate without counting the intercostal spaces. If it cannot

be felt still, check on the right hemithorax. You may be dealing with dextrocardia. Please

note that it is unlikely (though not impossible) that you will see a patient with

dextrocardia in the exam. In other words, you need to be doubly sure before you stick out

your neck, literally speaking.

 Check if the apex beat is diffuse (occupying 2 or more intercostal spaces). Feel for a thrill

at the apex. Check if the apex is heaving.

 Feel for a thrill at the left lower parasternal border. Check if the left lower parasternal

border is heaving.

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 Feel for thrill at the pulmonary area

 Feel for thrill at the aortic area.

 Proceed to auscultation. Though out your auscultation, your left thumb (or index with

middle fingers) must be seen to be palpating the right carotid artery to time your heart

sounds and murmurs. This may not be helpful practically but you must still do it. Why?

Convention! Just pass the exam and go!

 Start with the diaphragm.

Proceed in this order: apex – left lower parasternal border- pulmonary area-aortic area.

If you hear a systolic murmur (there is 80% chance any murmur you hear is going to be

systolic), ask the patient to breathe in deeply and hold it for a few seconds while your

stethoscope’s diaphragm is still at the area where the murmur is loudest (usually, apex

and left lower parasternal area),. Then the patient breathes out deeply and holds it for a

few seconds.

The books say that this will help you to distinguish right sided from left-sided murmurs

but the truth is, under examination tension, it adds little or nothing but you must be seen

to have done it. Note additional sounds such as the third heart sound ‘S3’ or the fourth

heart sound ‘S4’.

 Switch the stethoscope from the diaphragm to the bell and pretend to check as if you

want to ascertain that the bell is louder by hitting the bell with your knuckles.

Proceed in this order: left carotid artery – right carotid artery – aortic area – pulmonary area –

left lower parasternal border – apex. If you hear a pansystolic murmur, move from the apex

and end at the axilla with the bell.

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 Patient is asked to sit up again (the second and last sitting up in this examination. Can

you remember the first sitting up during the examination of the jugular venous pulsation-

I resisted the temptation to say ‘JVP’).

There are 3 things you want to do when the patient is seated up:

1. If you heard an early systolic murmur in the aortic area suggestive of aortic

stenosis (it’s only a 10% chance that you would hear an aortic stenosis murmur in

this exam. Be smart enough, doctor!), place the diaphragm on the aortic area,

auscultate with the patient leaning forward.

2. Listen to the lung bases. Ask the patient to breathe in and out.

3. Check for sacral oedema.

QUICK GENERAL PHYSICAL EXAMINATION

 The patient is asked to lie down back and you will do a quick general physical

examination from head to toe. The truth is that though it is called general physical

examination but it is not general physical examination per se. Rather, you just want to

elicit some further signs that will enable you substantiate you suspected diagnosis.

Therefore, don’t spend the whole day on this section.

 Observe if the patient is wasted or bloated. Observe again if dyspnoeic/tachypnoeic at

rest. Observe if there is a goitre. Check for the fluffiness of the hair. Check for jaundice

and pallor.

Ask the patient to open his mouth, shine your pen torch and check for buccal mucosal

moistness then cyanosis. If warm to touch, ask for a thermometer. Check if the hands are

cool and clammy. Check for finger clubbing and observe the nail bed for peripheral

cyanosis.

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  Ask the patient if he feels pain in the abdomen. Palpate the liver if palpably enlarged

below the costal margin. If enlarged, check for hepatic tenderness.

 Move to the foot of the bed

 Observe if there is wrinkling of the feet (Washerman’s sign). Check for pitting pedal

oedema.

 Thank the patient

 Attempt to cover him up

 Thank the examiner (whether he deserves it or not!)

 Apply your hand sanitizer

 Gather your thought until prompted to present your findings.

PRESENTATION OF EXAMINATION FINDINGS

Your presentation goes as written below (of course, this is just a prototype!):

Good morning Sir/Ma (you just have to greet him/her again!)

I have done the cardiovascular examination of this middle-aged man.

The pulse rate was 96 beats per minute, regular, small volume. Arterial wall was not thickened.

There was no radio-radial or radio-femoral delay. Other peripheral pulses were also palpable.

Locomotor brachialis was not observed.

The blood pressure was 130/80 mmHg (even if you did not do the blood pressure you must still

say the figure you were given as if you did it yourself. If you were not given any figure, still say

so. You must never skip the blood pressure during your presentation).

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Jugular venous pressure (not pulsation, please!) was raised to about 5 cm above the

manubriosternal angle.

Precordium was hyperactive. The apex beat was at the 6th left intercostal space, anterior axillary

line. It was heaving but no thrill was felt. There was no left lower parasternal heave and no thrill

was felt throughout the precordium. I heard the first, second and third heart sounds (not S1, S2,

S3 please!). I also heard a grade 3/6 pansystolic murmur loudest at the apex, louder in expiration

and radiating to the axilla suggestive of a mitral regurgitation murmur. No carotid bruit was

head. Bibasal crackles were heard.

Patient did not have fluffiness of hair. He was not pale, anicteric, well hydrated, not cyanosed,

and not febrile. The peripheries felt cold. There was no finger clubbing. The liver was not

palpably enlarged below the right costal margin. There was bilateral pitting pedal oedema up to

mid-legs with washer man’s sign observed.

FORMULATION OF DIFFERENTIALS

This is technical because it depends on the patient whose history you are not privileged to know.

So, the following suggestions are not exhaustive but helpful.

In the Cardiovascular station, there are usually 2 options:

1. Features in keeping with hypertensive heart disease (for example, thickened arterial wall,

elevated blood pressure, displaced heaving apex, fourth heart sounds, loud A2 and so on)

2. Features in keeping with heart failure (for example, small volume pulse, raised jugular

venous pressure, third heart sounds with gallop, Bibasal crackles, tender hepatomegaly,

pitting pedal oedema and so on)

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TIPS

 If the features are in keeping with hypertensive heart disease, your diagnosis is

hypertensive heart disease. However, if the blood pressure is not elevated but has

features suggestive of hypertensive heart disease, your diagnosis is hypertensive heart

disease, possibly on treatment.

 The differentials (which you will surely be asked) are a bit challenging but here is the

way to wriggle yourself out. You say something like this:

 I am also thinking of hypertrophic cardiomyopathy however, I don’t expect the

blood pressure to be raised (if the patient’s blood pressure is raised) although an

individual can have hypertrophic cardiomyopathy and systemic hypertension

concurrently but I still think the patient I have examined most likely has

hypertensive heart disease. Finish!

 Another differential I am also thinking of is aortic stenosis considering that this

patient’s apex beat is displaced and heaving. He also has a fourth heart sound.

However in the absence of an aortic stenosis murmur (you quickly let the

examiner know that you can recognize an aortic stenosis murmur- early systolic

murmur, loud in the aortic area, louder in expiration and better heard with a

patient sitting up and leaning forward), I wouldn’t consider this on top of my

differentials. Finish!

 If the features are in keeping with heart failure, the possible differentials (in the absence

of history) will depend on

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 a. Approximate age of the patient

b. Presence or absence of elevated blood pressure.

 If there are features of heart failure with prominent murmurs, the patient is young

and the blood pressure is not elevated, the order of your differentials will be:

i. heat failure secondary to valvular heart disease

ii. heart failure secondary to dilated cardiomyopathy

iii. heart failure secondary to hypertensive heart disease, possibly

on treatment or in end-stage hypertensive heart disease

 If there are features of heart failure with prominent murmurs, the patient is

middle-aged or elderly and the blood pressure is not elevated, the order of you

differentials will be:

i. heart failure secondary to dilated cardiomyopathy

ii. heart failure secondary to hypertensive heart disease, on

treatment or in end-stage hypertensive heart disease

iii. heart failure secondary to valvular heart disease

 If there are features of heart failure, the and the blood pressure is elevated, the

order of you differentials will be:

i. heart failure secondary to hypertensive heart disease

ii. heart failure secondary to dilated cardiomyopathy with possibly

concurrent systemic hypertension

iii. heart failure secondary to valvular heart disease with possibly

concurrent systemic hypertension

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  If there are features of heart failure with prominent murmurs, the patient is very

young (less than 30 years by approximation) and the blood pressure is not

elevated, the order of you differentials will be:

i. heart failure secondary to valvular heart disease

ii. heart failure secondary to congenital heart disease

iii. heart failure secondary to dilated cardiomyopathy

 If there are features of heart failure and the patient has a goitre (a reason why you

must observe), your differentials must include heart failure secondary to

thyrotoxic heart disease

 Note that ischaemic heart disease is difficult to substantiate in PACES. However, if the

patient has observable prominent cardiovascular risks such as hypertension and obesity

with features of heart failure, heart failure secondary to ischemic heart disease can be

your number 5 differential (if the examiner forces you to keep giving differentials

otherwise, it is better avoided).

 If there are murmurs and patient is febrile, infective endocarditis should be in your

differentials.

 Sometimes, you are asked to state the precipitant of the heart failure. The following tips

may be helpful

 If the pulse rhythm is clearly irregular, then arrhythmia is a possible

precipitant.

 If the patient is febrile and has tachycardia (which is highly likely,

anyway), then sepsis? focus is a possible precipitant

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  If the blood pressure is clearly elevated (above 150/90 for example), the

precipitant is possibly uncontrolled hypertension.

 If the patient has features of heart failure, a common question is ‘Is this patient in failure

now?’

Rule of thumb: In PACES, “heart failure now” means: tachypnoea, tachycardia, S3

gallop, bibasal crackles and soft tender hepatomegaly.

In case you get confused (which is not impossible under exam tension), if the patient is

not dyspnoeic/tachypnoeic right now, he is not likely to be in failure right now. In that

case, a correct answer (for example) will be: heart failure secondary to dilated

cardiomyopathy, most likely on treatment.

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 CHAPTER 2

ABDOMINAL EXAMINATION

 Greet the examiner

 Move straight to the right side of the patient. Even if you are left-handed, endeavour to

practice with the right side because you don’t want to start unnecessary argument with

the examiner at this stage.

 Greet the patient

 Introduce yourself to the patient, allay his fears and obtain consent.

 Screen the patient or pretend as if you want to screen if patient is already screened.

 Apply your hand sanitizer. Endeavour to come with your own hand sanitizer.

 Ensure patient is adequately exposed. For the purpose of abdominal examination,

exposure is from the nipple line to the inguinal region. Please don’t expose the genitalia.

Some books say that you should expose to mid-thigh. In this exam, NO!

 Position the patient appropriately. Anatomical position is what you want. Request that

you want the bed to be flat, if comfortable for the patient. Patient’s comfort takes

precedence over anatomical position but you must be seen to have attempted to place the

patient in anatomical position.

 Take a quick look around the patient’s bedside. Observe if patient is on intravenous fluid

infusion, if he has a urethral catheter, nasogastric tube. These things might seem simple

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 and obvious, but if you don’t deliberately look for them, you may not observe, under

exam tension.

 At the right side of the patient, bend such that your eyes are at the level of the abdomen.

What you are looking for is to compare the contour of the chest with the contour of the

abdomen.

If the abdomen contour is at a higher level compared with the chest, then the abdomen is

either full or distended. Shortly, you will be shown how to differentiate between the two.

If the abdomen contour is roughly at the same level with the chest contour, the abdomen

is flat.

If the abdomen contour is lower than the chest contour, the abdomen is scaphoid.

Therefore, you are not just bending but you want to observe something objectively

 While bending, you also want to observe if there is epigastric or suprapubic fullness.

 Move to the foot of the bend such that your eyes are at the level of the abdomen.

What you want to do here is to compare the right side of the abdomen with the left

looking for asymmetry.

Pay attention to the presence of right hypochondriac fullness. That may be where the

answer is!

After that, compare the contour of lateral chest wall with the contour of the lateral

abdominal wall, if the lateral abdominal contour is more lateral to the lateral chest

contour then it suggests that the abdomen is distended rather than just full- this is the

second step to differentiate the two as stated earlier.

 Go back to the right side of the patient and take a few seconds to look at the anterior

abdominal wall very well. What are you looking for?

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  Scars and scarifications. Take note of the Pfannenstiel scar in women

otherwise you may miss it (modern Gynaecologists are very good!).

 Umbilicus: whether inverted, flat, everted or there is umbilical hernia

 Anterior abdominal wall veins.

 Visible peristalsis.

 Lift the cloth off the genitalia so that you can appreciate the inguinal region but don’t

expose the genitalia completely.

Tell the examiner to excuse you from the left side of the patient (the examiner is likely

going to be on the left side) because the patient is going to cough in that direction.

Tell the patient to turn the neck to the left and cough

You should take note of visible cough impulse for inguinal hernia, umbilical hernia or in

any other area on the abdominal wall

Place your hands on the inguinal areas and ask the patient to cough again, feeling for

palpable cough impulse

Examine the testes gently, one after the other and note the volume in case you may need

to submit chronic liver disease later.

Release the cloth to cover the genitalia back while you proceed.

 Determine the direction of the abdominal veins, if present

 Ask specifically for pain in any region of the abdomen

 Palpate the umbilicus and surrounding area for nodules

 Do superficial palpation, starting furthermost from the region that is painful.

 Do deep palpation. This is when to ‘stylishly’ determine if there is hepatomegaly or

splenomegaly. Be smart enough sir!

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 Examine if the liver is palpably enlarged. This is done by deep palpation, starting from

the right iliac fossa and moving superiorly.

Ask the patient to be breathing in and out while you palpate during expiration.

Note that if there is massive ascites, you ballot for the liver instead of palpating for it

 If the liver is palpable, measure the length from the right costal margin. Show an

imaginary mid-clavicular line to the examiner and indicate that you are measuring along

that line.

After measurement, check if the liver is soft, firm or hard. Check if the surface is smooth

or nodular. Check if the edge is rough or smooth.

 Examine if the spleen is palpably enlarged. This is done by deep palpation, starting from

the right iliac fossa and moving initially medially then later superiorly towards the left

hypochondriac region.

Ask the patient to be breathing in and out while you palpate during expiration.

If you can’t feel anything, ask the patient to lie on the right side and attempt to

bimanually palpate for the enlarged spleen again. If you still can’t feel the spleen, let the

patient lie supine and proceed to the next step

 Bimanually palpate for the kidneys. The hand behind the flank must be constantly behind

the flank on both sides (You don’t change a winning kidney!)

 Percuss for the liver span (please, percuss very audibly so that the examiner can hear).

Follow the order below:

Start your percussion from the chest.

Locate the second right intercostal space objectively using the manubriosternal angle as

the reference point and start your percussion from there.

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 When you hear the hepatic dullness, determine the number of that intercostal space.

You don’t need anybody to touch the place for you once you determine the number.

Start another percussion from the right iliac fossa.

When you hear the hepatic dullness, determine the point of dullness bring out a tape

measure.

With your left hand, hold the end of the tape measure at this point of dullness.

Hold the remaining part of the tape measure in your right hand.

Use your right hand to locate the second intercostal space.

Count the intercostal spaces to the predetermined number you got earlier

Extend the tape measure firmly with your right hand and measure the liver span along the

right mid-clavicular line.

If you follow these steps, you really do not need any assistant.

 Check for ascites

If the abdomen is tense, check for ascites by doing the fluid thrill. The patient may assist

you. If the examiner volunteers to assist you, all well and good

If the abdomen is not tense, do shifting dullness by percussion. The following are the

steps in doing shifting dullness:

The pleximeter finger (the finger on the abdominal wall) must be above the level of the

umbilicus at all times. Check the shifting dullness to the right and then to the left. It must

be done to both sides, one after the other except there is massive hepatomegaly or

splenomegaly in which case there will be no sense percussing to the side of the enlarged

organ because it’s always going to be dull anyway. In the absence of massive

hepatomegaly and/or splenomegaly, shifting dullness is done as follows.

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 Percuss from the midline above the umbilicus to the right side, while patient is lying

supine. When you get to the point of dullness, the pleximeter finger stays there while you

ask the patient to roll to his/her left side. Wait for about 10 seconds and percuss the same

site where the pleximeter had been fixated on earlier. If the percussion note is now

resonant (from the initial dullness) shifting dullness has been successfully demonstrated.

Reverse the steps for the left, starting all over again from the supine position. Note that

the pleximeter finger has not shifted rather, it is the dullness that has ‘shifted’ to

resonance at the same spot as a result of rolling to the contralateral side.

 Check for renal angle tenderness. Ideally, renal angle tenderness is still a part of

‘percussion’ because you are hitting something.

 Listen to the bowel sounds

 Listen for the renal bruit (3 cm superior and lateral to the umbilicus at both sides).

 Listen for hepatic bruit

 Request that you want to do a digital rectal examination

 Go ahead and do a quick general physical examination

QUICK GENERAL PHYSICAL EXAMINATION

 You would have noticed by now if the patient is wasted

 Check for fluffiness of the hair

 Check for jaundice

 Check for pallor

 Ask the patient to open the mouth and shine your light looking for mucosal wetness or

pigmentation.

24
 Note if there is parotid fullness.

 Note if the patient (if male) has sparse beards. Hypogonadism in cirrhosis makes them

lose their beards.

 Check for peripheral lymphadenopathy

 Specifically feel for left supraclavicular lymph nodes

 Shine the light at the axilla, looking for sparse axillary hair

 Observe for gynaecomastia

 Examine the hands. Check for:

 palmar erythema

 Loss of thenar & hypothenar eminence

 Dupuytren’s contracture

 Leuconychia

 Finger clubbing

 Asterixis (especially if jaundiced)

 Check for pitting pedal oedema. Observe wrinkling (Washerman’s sign)

 Thank the patient

 Cover the patient

 Thank the examiner (for what? just thank him all the same)

 Apply your hand sanitizer again

 Gather your thought until prompted to present.

25
 PRESENTATION OF EXAMINATION FINDINGS

Your presentation goes as follows: (of course this is just a prototype)

Good morning Sir/Ma. I have done the abdominal examination of this middle-aged man.

The abdomen was distended and moved with respiration. There was a right hypochondriac

fullness. No scars or scarifications. No distended veins or scars. No visible or palpable cough

impulse. Umbilicus was everted but no palpable nodules around it. There was moderate

tenderness on palpating the right hypochondriac region.

The liver was palpably enlarged about 12cm below the right costal margin along the

midclavicular line. It was nodular, hard and tender with a rough edge.

The spleen was not palpably enlarged and the kidneys were not bimanually palpable. There was

hepatomegaly with liver span of 18cm.

Ascites was demonstrable by shifting dullness. There was no renal angle tenderness. Bowel

sounds were normoactive. No renal or hepatic bruits were heard.

You did not permit me to do the digital rectal examination.

On quick general physical examination, the patient was chronically ill-looking as evidenced by

atrophy of temporalis muscle and prominent zygomatic bones bilaterally.

The hair was fluffy. He was icteric, not pale, well hydrated. No parotid fullness was observed.

No significant lymphadenopathy. The axillary hair was absent although I did not ask whether he

had recently shaved his axilla.

26
There was loss of thenar and hypothenar eminence. No palmar erythema. No Dupuytren’s

contracture, but there was leuconychia. There was grade 3 finger clubbing but no asterixis.

Washerman’s sign was observed and there was pitting pedal oedema up to the mid-legs.

FORMULATION OF DIFFERENTIALS

This is technical because it depends on the patient before you. So the following suggestions are

not exhaustive but helpful.

The summary of your finding should fall into any of the following categories:

1) Nodular hepatomegaly with ascites ± jaundice

Differential diagnoses of this include:

- Primary liver cell carcinoma

- Metastatic liver disease ( you say, ‘I am not sure of the primary origin at the

moment’)

- Abdominal tuberculosis

- Intra-abdominal lymphoma

- There is a caveat here: if the patient is pale, metastatic liver disease comes first. If the

patient is not pale, primary liver cell carcinoma comes first.

2) Smooth hepatomegaly with ascites with or without jaundice

Differential diagnoses of this include

a. Chronic hepatitis (for example, alcoholic)

27
 b. Heart failure, especially if patient is not comfortable lying flat. You quickly add

that you would have loved to do cardiovascular examination to substantiate your

submission.

c. Abdominal tuberculosis is still possible.

3) Shrunken liver (liver span < 8cm) with ascites ± jaundice

Differential diagnoses of this include

a. Decompensated liver cirrhosis

b. Massive ascites 20 to abdominal tuberculosis possibly involving the peritoneum

If there is pedal oedema, ascites and leuconychia, think of hypoproteinemic state such

as protein-losing enteropathy or nephrotic syndrome.

4) Hepatomegaly only

Differential diagnoses of this include

a. Chronic hepatitis (for example, alcoholic)

b. Haematological malignancy (especially if pale and wasted)

c. If young, asthenic and jaundiced, think of sickle cell disease

5) Hepatosplenomegaly

Differential diagnoses of this include

a. Haematological malignancy

28
 b. If the patient is young, sickle cell disorder (you quickly add haemoglobin SC

before the examiner will raise his voice at you!)

c. Abdominal TB is still a possibility

d. Infectious diseases such as Leishmaniasis, Histoplasmosis are remote

possibilities.

6) Splenomegaly only

Differential diagnoses of this include

a. Haematological malignancy, possibly CML

b. If the patient has ascites with the splenomegaly, chronic liver disease with

portal hypertension is a possibility.

c. Infectious diseases such as Leishmaniasis, brucellosis are possibilities.

PLS NOTE THAT THEY HAVE BROUGHT “NORMAL PATIENTS” BEFORE. If you cannot

find any sign, just say so (I commit you into the hands of the Lord!).

29
 CHAPTER THREE

CHEST EXAMINATION

 Greet the examiner

 More straight to the right side of the patient.

 Greet the patient, introduce yourself, allay his fears and obtain consent

 Screen the patient or pretend you want to screen if he had already been screamed.

 Apply the hand sanitizer

 Expose the patient adequately

 Position the patient in anatomical position if comfortable for the patient. Patient’s comfort

takes precedence over anatomical position

 Take a quick look at the patient if there is any intravenous fluids, chest tube, nebulizer,

oxygen cylinder and so on.

 Ask for the sputum bowl, if any.

 Bend such that your eyes are at the level of the chest at the right side of the patient

- Observe chest wall movement

 Go to the foot of bed and bend again such that your eyes are at the level of the chest.

Compare the right hemithorax with left hemithorax, looking for chest movement. Also,

observe if there is any apical flattering

 Come back to the right side

 Look all over the chest wall

Bend very well to look at the lateral side of the left hemithorax as if you want to bury your

head in the hemithorax. Of course, you must show some respect to a female patient.

30
 - Look for scars

 Note if the chest is barrel shaped

Measure the anteroposterior diameter using the tape measure from the midline anteriorly

to the midline posteriorly along the nipple level.

Measure the transverse diameter using the tape measure from the mid-axillary line on the

right to the mid-axillary line on the left along the nipple level.

If the anteroposterior diameter is greater than the transverse diameter, it suggests a barrel

shaped chest, a feature of hyperinflation in obstructive airway disease.

 Count the respiratory rate by holding the wrist as if you are counting the radial pulse

 Check if the patient is dyspnoeic.

 Check for centrality of the trachea

 Divide the anterior wall into three zones and check for chest expansion in each zone

 Check for tactile fremitus, comparing the left with the right in each of the three zones on

the anterior chest wall and two zones on the lateral chest wall.

 Percuss the chest wall anteriorly and laterally, comparing the right with the left

Proceed in the following order:

Start on the right supraclavicular fossa

left supraclavicular fossa

right clavicle {the clavicle is percussed only with the plexor finger (the hitting

finger)}

left clavicle

right upper lung zone,

left upper lung zone,

31
 right middle lung zone

left middle lung zone

right lower lung zone

left lower lung zone

right lateral zone

left lateral zone

right upper lateral lung zone close to the axilla

the left lateral lung zone close to the axilla. – smooth and systematic!

 Listen to the breath sounds following the zones as earlier described.

 Auscultate for vocal resonance.

 If there are features suggestive of consolidation in any zone, check for egophony and

whispering pectoriloquy in that zone

 Ask patient to sit up for posterior wall examination,

 The forearms are crossed on the anterior chest wall as if you are forming the danger sign X.

This is done to move the scapula away from your region of examination, as mush as possible.

- Inspect again

- Check for chest expansion (some authorities claim you don’t do chest expansion on

the posterior chest wall). The convention is to do, most likely the candidate before

you would do it, so follow the convention.

- Do tactile fremitus moving systematically from one zone to the other and comparing

the right with the left. The right upper lung zone - left upper lung zone - right middle

lung zone - left middle lung zone - right lower lung zone - left lower lung zone.

- Percuss the chest systematically following the zones as earlier documented.

32
 - Auscultate for breath sounds and added sounds.

- Check for vocal resonance.

QUICK GENERAL PHYSICAL EXAMINATION

 Ask the patient to lie down back so as to do a quick genial physical examination.

- Check for fluffiness of the hair

- Check for jaundice, pallor,

- Ask the patient to open the mouth, check specifically for cyanosis

- Check for fever (request for a thermometer if the patient is warm to touch)

- Check for peripheral lymph nodes enlargement

- Check for finger clubbing

- Check for asterixis (if you are suspecting obstructive airway disease with respiratory

failure)

- Check for pitting pedal oedema

- Thank the patient, cover the patient and apply the hand sanitizer

- Thank the examiner

PRESENTATION OF EXAMINATION FINDINGS

Your presentation goes as follows (of course this is just a prototype).

Gather your thought until prompted to speak

Good morning Sir/Ma,

33
I have done the chest examination of this middle-aged man. He was not tachypnoeic, respiratory

rate was 18/min and he was not dyspnoeic also. No previous scars. There was apical flattening of

the left. Trachea was central. Chest wall appeared symmetrical.

Chest wall movement and expansion were reduced on the left upper lung zone. Tactile fremitus

was increased on the upper left zone. Percussion note was resonant but dull on the left upper lung

zone. Breath sound was vesicular but reduced on the left upper lung zone. There were fine

crackles on the left upper lung zone.

A quick general physical examination revealed a middle-aged man who was chronically ill-

looking, pale, anicteric, not cyanosed, well hydrated, and afebrile. He had no significant

peripheral lymphadenopathy, no finger clubbing, no asterixis, no pedal oedema.

FORMULATION OF DIFFERENTIALS

This is technical because it depends on the patient before you so the following suggestions are

not exhaustive but helpful.

 The first step to making a diagnosis after chest examination is by having a pathological

summary. Fortunately, the pathological summaries in chest examination are conventional.

They include:

1. Consolidation:

a. Lobar pneumonia (you quickly add likely on treatment if patient is afebrile and

not dyspnoeic)

b. Lung mass possibly malignancy

c. Lung infarction

34
2. Pleural effusion:

a. Right sided pleural effusion likely secondary to pulmonary tuberculosis to rule

out the malignancy.

b. Parapneumonic effusion

3. Hyperinflation:

a. COPD if middle-aged to elderly and you add ‘

- in respiratory failure’, if there is cyanosis, dyspnea, asterixis.

- With possibly pulmonary hypertension if there is pedal oedema

(you quickly add that a full cardiovascular examination would

have been helpful to substantiate this suspicion).

b. Asthma if young

Each could be a differential of the other.

4. Lung fibrosis

You need to ask if it is upper or lower lung zone fibrosis

Upper long zone: Tuberculosis

Sarcoidosis

Aspergillosis

Histoplasmosis

Silicosis

Lower long zone: Idiopathic fibrosis

Asbestosis

35
 Rheumaloid arthritis

Drugs (nitrofurantoin, hydralazine, methotrexate)

PECULIAR SITUATIONS:

 Sometimes, it is difficult to categorize into a particular pathological summary. Think of

double summaries e.g.

 Hyperinflation with crackles on a particular zone. The differentials will include

a. Acute exacerbation of COPD

b. Acute exacerbation of asthma

 Hyperinflation on one side and effusion on the other side. Think of right sided

pleural effusion with compensatory hyperinflation on the other side.

 Scattered crackles all over the chest, no particular summary

- Pulmonary oedema

- Bronchopneumonia

- Tuberculosis possibly with superimposed bacterial infection

- Pulmonary fibrosis

 Bibasal crackles

i. Heart failure

ii. idiopathic pulmonary fibrosis

 Widespread wheezing and crackles

i. Bronchiectasis

ii. Acute exacerbation of COPD

iii. Pulmonary oedema

36
 CHAPTER FOUR
NEUROLOGICAL EXAMINATION

INTRODUCTION

Read the question carefully. It could go in any of the following format:

- Examine the motor system of this patient

- Examine the motor system of the upper limbs of this patient

- Examine the motor system of the lower limbs of this patient

Rule of thumb: All these questions are almost the same because you will do almost the same

thing but the arrangement, emphasis and order will not be the same. Of course, your differentials

too may not be the same.

So, we go with the commonest question: Examine the motor system of this patient.

 Greet the examiner

 More straight to the right side of the patient.

 Greet the patient, introduce yourself, allay his fears and obtain consent.

 Screen the patient or pretend as if you want to screen if the patient is already screened

 Apply the hand sanitizer

 Position the patient in anatomical position

 Neurological examination started when you greeted the patient (was he aphasic or

dysphonic?)

 Take a quick look of the surrounding (any wheel chair, walking aid around the patient)

 Look for externally rotated limbs (especially lower limbs)

37
 Inspect the muscle groups

` Right arm then left arm

Right forearm then left forearm

Right hand (Looking for small muscle wasting) then left hand

Right thigh then left thigh

Right leg then left leg

Right foot (looking for small muscle wasting) and then left foot

 If you noticed obvious asymmetry, then measure each muscle group as described in order to

be objectively convinced of atrophy (wasting)

 Measure 10cm upwards from the right elbow (olecranon specifically) and measure their

circumferences of the right arm. Do the same for the left arm.

 Measure 10cm downwards from the right elbow (olecranon specifically) and measure the

circumference of the right forearm. Do the same for the left forearm.

 Measure 15cm upwards from the right patella, measure the circumference of the right thigh.

Do the same for the left thigh.

 Measure 10cm downwards from the right tibial tuberosity measure the circumference of the

right leg, do the same for the left leg.

 Check for fasciculation by flicking each muscle group with your finger.

Right arm then left arm

Right forearm then left forearm

Right thigh then left thigh

Right leg then left leg

 Check the tone around each joint

38
  Do circumduction for the right shoulder and do the same for left

 Do flexion and extension of the right elbow then the left elbow

 Do the rotation of the right wrist then the left

 Do circumduction of the right hip then the left hip

 Do flexion and extension of the right knee then the left knee

 Do the dorsiflexion and plantar-flexion of the right ankle then the left ankle

 Check for power (upper limbs)

Right Left

Shoulder Flexion Flexion

Extension Extension

Abduction Abduction

Adduction Adduction

Elbow Flexion Flexion

Extension Extension

Wrist Flexion Flexion

Extension Extension

Thumb Abduction Abduction

Adduction Adduction

39
 Right Left

Fingers Flexion Flexion

Abduction Abduction

Adduction Adduction

 The power in the hand can be tested as a whole by asking the patient to squeeze your index

and middle fingers tightly while you attempt to withdraw the fingers. Do this for the left and

right hands simultaneously

 If there is no differential weakness (hemiparesis), check for pronator drift

 Grade the power using the Medical research Council grading.

 Check for power in the lower limbs

Right Left

Thigh Flexion Flexion

Extension Extension

Abduction Abduction

Adduction Adduction

Leg Flexion Flexion

Extension Extension

40
 Right Left

Foot Plantar flexion Plantar flexion

Dorsiflexion Dorsiflexion

Big toe Flexion Flexion

Extension Extension

 Check for reflexes:

Right biceps reflex then left biceps reflex

Right triceps reflex then left triceps reflex

Right brachioradialis reflex then left brachioradialis reflex

Right knee reflex then left knee reflex

Right ankle reflex then left ankle reflex

 If there is hyperreflexia,

Check for ankle clonus

 Check for plantar response: flexor or extensor or equivocal

 Go to the foot of the bed and ask the patient to smile checking for fascioparesis. If present,

move close to the patient, stabilize the head and ask him to wrinkle the forehead by looking

up (with the head stabilized) so as to check if the fascioparesis is upper motor neuron type or

not.

 Tell the examiner you would like the patient to walk so as to examine the gait

41
  Observe the gait

 Look for triple flexion of the upper limb and hemiplegic gait or any other gait

present

 Guide the patient back to his bed

 Cover him up

 Thank the patient

 Thank the examiner

 Apply your hand sanitizer

 Gather your thought until prompted to speak.

PRESENTATION OF EXAMINATION FINDINGS

Your presentation goes as follows:

Good morning Sir/Ma,

I have examined the motor system of this middle-aged man. The right lower limb was noticed to

be laterally rotated. Muscle bulk was reduced in the right upper and lower limbs evidenced by

measurement done with similar landmarks. There was no fasciculation

There was hypertonia in the right upper and lower limbs. There was hemiparesis on the right.

Power in the right upper limb is Grade 3 and Grade 4 in the lower limbs using the Medical

research council grading. There was hyperreflexia in the right upper and lower limbs. Ankle

clonus was also demonstrated on the right limbs. Plantar response was extensor on the right but

flexor on the left. The patient was also noted to have right fascioparesis, upper motor neuron

type. The gait was hemiplegic.

42
FORMULATION OF DIFFERENTIALS

This is technical because it depends on the patient before you. So, the following suggestion are

not exhaustive but helpful.

 The first step to making differentials diagnosis is by determining the neurological summary.

The conventional summaries include (but not limited to):

1. Spastic hemiparesis (either right or left)

2. Flaccid hemiparesis (either right or left)

3. Spastic paraparesis

4. Flaccid paraparesis

5. Spastic monoparesis

6. Flaccid monoparesis

7. Small muscle wasting (usually the hand)

Spastic hemiparesis

Contralateral stroke (e.g. left hemispheric stroke for right hemiparesis) which could be ischemic

or haemorrhagic.

Differential diagnoses:

 Left sided space occupying lesion e.g. tumour, tuberculoma

 Left sided subdural hematoma

43
Flaccid hemiparesis:

Many causes of spastic hemiparesis can also cause flaccid hemiparesis if patient is still in

neuronal shock, so you could say right hemispheric stroke probably still in spinal shock if the

patient is still very ill.

Spastic paraparesis

 Traumatic cord compression

 Pott’s disease

 Compressive myelopathy due to tumour (either primary or metastatic )

Flaccid paraparesis

Some causes of spastic paraparesis such as traumatic cord compression of can also cause flaccid

paraparesis if the patient is still in spinal shock. Other cause will include:

 Guillain–Barre syndome

 Chronic inflammatory demyelinating polyneuropathy.

 Poliomyelitis (likely from childhood)

 Diabetic radiculoplexopathy (Bruns-Garland syndrome)

Hand small muscle wasting

 Radiculopathy probably from cervical spondylomyelopathy

44
  Brachial plexopathy probably 20 to tumour infiltration or cervical rib

 SPECIAL CONSIDERATIONS

If you are asked to examine the motor system of the upper limbs only and there is objective

monoparesis, you need to do a quick examination of the lower limbs too. Also, if you are asked

to examine the motor system of the lower limbs only, you need to do a quick examination of the

upper limbs too. There is a 60-70% chance that the patient actually has hemiparesis which may

essentially alter your differentials.

45
 CHAPTER FIVE
THYROID EXAMINATION

Thyroid examination is done with patient seated on a chair. If you enter a thyroid station and

patient is lying on the bed, this is a catch some-where or you are in the wrong station.

 Greet the examiner

 Greet the patient

 Introduce yourself, allay her fears and obtain consent.

 Ask her politely to remove her headgear (Be sensitive to religious beliefs on head coverings.

So, you need to be as polite as possible).

 Ask for a cup of water if not provided already

 Apply hand sanitizer

 Observe if patient is restless, sweaty or anxious.

 Bend in front of the patient so that your eyes will be at the level of the thyroid

Your aim here is to observe any asymmetry between the right and left lobes.

 Bend at the right side of the patient. Your aim here is to compare the contour of the neck with

the contour of the thyroid. If the contour of the thyroid is more anteriorly located, there is

objective evidence of goitre.

 Bend on the left side too to confirm what you saw on the right i.e. comparing the contour of

the neck with the contour of the thyroid.

 Move closer to the patient. Inspect for previous thyroidectomy scar (check very well because

the modern endocrine surgeons are very good with their incisions!)

46
 Tell the patient that you would give her/him a cup of water, she/he should take a gulp, hold it

in the mouth until you tell her/him to swallow. You must be seen to have given this

instruction.

 After giving the instruction ask her to carry out what you have instructed her to do. Your aim

is to check whether the mass moves with swallowing.

 Ask her to protrude her tongue and check whether the mass moves with tongue protrusion. A

thyroglossal cyst will move with tongue protrusion but goitre won’t move with tongue

protrusion.

 In this exam, this is a 90% to 95% chance that the anterior neck mass you would have is a

goiter rather than thyroglossal cyst. Be smart enough!

 Feel for differential warmth

 Check for tenderness

 Measure the dimensions of each lobe: longitudinal and latitudinal diameters

 Go to the back to palpate the goitre properly.

 Repeat the water instruction again and ask her to drink water

 Palpate for consistency, smoothness and mobility

 Palpate the carotid artery

 Palpate for different groups of neck lymph nodes including sub-occipital lymph nodes

 Look from upward over the head to check for proptosis

 Observe if she has alopecia

 Move back to the front of the patient

 Percuss for retrosternal extension

 Auscultate the upper pole of each lobe for bruit

47
 Auscultate for carotid bruit.

Note that the bruit is heard with the bell of the stethoscope.

 Observe lid retraction. How? If you could see the sclera above or below the limbus, then

there is lid retraction

 Check for lid lag

 Observe Joffroy’s sign (absence of normal wrinkling of the forehead)

 Check for extraocular muscle movement using the conventional figure of ‘H’

 Check for accommodation

 If the thyroid glands is huge, check for Pemberton’s sign. This is done by asking the patient

to raise up his arms up for a while and you observe for noisy breathing

 Coincidentally, as you are checking for Pemberton’s sign, you are also indirectly checking

for proximal myopathy.

 Examine the hands. There are at least 7 things you will check for:

1. Sweatiness of the palms

2. Warmth

3. Palmar erythema

4. Tremor

5. Onycholysis

6. Finger clubbing (thyroid acropachy)

7. Radial pulse – count the rate and note the rhythm

48
  Ask for sphygmomanometer to do the BP (I pray the examiner won’t give it to you

otherwise, you won’t be able to finish your examination in 3 minutes). Nevertheless, you

must still ask, why? Convention!

 Feel for pretibial myxedema

 Check for pedal oedema (whether pitting or not)

 Check for ankle reflexes

 Thank the patient

 Tell her to wear her headgear back

 Thank the examiner

 Apply your hand sanitizer

 Present your findings

PRESENTATION OF EXAMINATION FINDINGS

Your presentation will go as follows:

Good morning Sir/Ma,

I have done the neck examination of the patient. Patient was sitting calmly on the chair, not

sweaty. There was an anterior neck mass which moves with swallowing but not with tongue

protrusion. The right lobe measures 8 cm x 4 cm whereas the left lobe measures 6 cm x 6cm. no

scar or sinus was noted. There was no differential warmth or tenderness.

49
It felt nodular, firm and was freely mobile. The carotid pulsation was felt. No lymph node was

felt. No clinical evidence of retrosternal extension. No bruit was heard. Carotid bruit was also not

heard. The eyes were proptosed

There was lid lag and lid retraction. However, the extraocular muscle movement was intact.

Accommodation was intact. Joffroy’s sign was absent. Pemberton sign was absent. No evidence

of proximal myopathy at least in the upper limbs where I checked.

The hand was warm but not sweaty. There was no palmar erythema or onycholysis. There was

finger tremor but no finger clubbing.

The pulse rate was 92beats per minute, regular, normal volume. There was no

sphygmomanometer to do the blood pressure

There was no pretibial myxedema. Ankle reflex was essentially normal

FORMULATION OF DIFFERENTIALS

This is technical because it depends on the patient before you. So the following suggestions are

not exhaustive but helpful.

There is something I call the thyroid quadrant of Azeez (Hmmm!)

Your thyroid examination findings will (or must) fall into one of the following

4 possible options depending on the nature of the thyroid and presence of toxicity

1. Simple diffuse goitre

2. Simple nodular goitre

50
 3. Toxic diffuse goitre

4. Toxic nodular goitre

From each quadrant, you can pick the differentials as follows:

1. Simple diffuse goitre. The differentials include:

a. Endemic goitre from iodine deficiency

b. Graves disease on treatment

If you don’t put ‘on treatment’, you are wrong.

c. Hashimoto’s disease on treatment

2. Simple nodular goitre. The differentials include:

a. Inactive thyroid adenoma

b. Inactive thyroid cysts

c. Thyroid abscess (if tender)

d. Simple multinodular goitre

e. Toxic multinodular goitre on treatment

If you don’t put on treatment, obviously, you are wrong

f. Thyroid malignancy

g. Thyroid granuloma e.g. thyroid TB

3. Toxic diffuse goitre. The differentials include:

a. Graves disease

b. Thyrotoxic phase of Hashimoto’s thyroiditis

Again, this can be either Toxic uninodular goitre or toxic mutinodular goitre

a. Toxic uninodular goitre. The differentials include:

 Autonomous Thyroid adenona

 Thyroid malignancy.

b. Toxic multinodular goitre. The differentials will include:

 Toxic multinodular goitre itself (also called Plummer’s disease)

 Nodular Graves disease (called Marine – Lenhart syndrome)

 Thyroid malignancy

52
 CHAPTER SIX
GENERAL PHYSICAL EXAMINATION

 Greet the examiner

 Move straight to the right side of the patient

 Greet the patient, introduce yourself, allay his fears and obtain consent

 Screen the patient or demonstrate as if you want to screen if he had already been screened

 Apply hand sanitizer

 Ensure adequate exposure

 Place the patient in anatomical position

 Take a quick look at the patient looking for IV fluid, any intubation, catheters, nasogastric

tube, femoral catheters and so on.

 Determine if he is wasted or bloated

 Does he have generalized oedema

 Check for fluffiness of the hair

 Check for jaundice

 Check for pallor

 Ask the patient to open her mouth while you shine your pen torch and assess the buccal

mucosa moistness

 Check for cyanosis

 Feel for body warmth. If warm, request for a thermometer.

 Ask the patient to sit up and check for cervical groups of lymph nodes

 While in the seated position, check for sacral oedema

53
 Then ask him to lie on his/her back

 Check for axillary lymph nodes, supraclavicular and infraclavicular lymph nodes in the body.

 Check for leuconychia and finger clubbing

 If patient has jaundice, check for features of liver palm.

 Check for half and half nails

 Check for asterixis

 Check for pitting pedal oedema

 Thank the patient

 Cover the patient up

 Thank the examiner

 Apply your hand sanitizer

 Present your findings

PRESENTATION OF EXAMINATION FINDINGS

Your presentation will go as follows:

Good morning Sir/Ma’am

I have done a general physical examination for this middle-aged man. He was chronically ill-

looking, with fluffiness of hair, anicteric, pale, well hydrated and afebrile. He had no significant

peripheral lymphadenopathy, finger clubbing, asterixis or pitting pedal oedema.

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FORMULATION OF DIFFERENTIALS

This is technical because it depends on the patient before you. So, the following suggestions are

not exhaustive but helpful. The following are the summaries of the main findings and their

differentials.

1. Generalized oedema

a. Chronic kidney disease

b. Nephrotic syndrome

c. Heart failure

d. Chronic liver disease

e. Protein-losing enteropathy/malabsorption syndrome

2. Pallor with pedal oedema

a. Chronic kidney disease

b. Anaemic heart failure

c. Chronic liver disease

3. Jaundice with wasting

a. Chronic liver disease

b. If relatively young, sickle cell disease

c. Metastatic liver disease

4. Jaundice with pedal oedema

a. Chronic liver disease

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 b. Cardiac cirrhosis

5. Generalized lymphadenopathy

a. Disseminated tuberculosis

b. Lymphoproliferative disease

c. Retroviral disease

d. Other infectious disease such as toxoplasmosis, leishmaniasis, histoplasmosis

syphilis

6. Pedal oedema alone

a. Heart failure

b. Chronic kidney disease

c. Chronic liver disease

d. Pelvic deep venous thrombosis

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 CHAPTER SEVEN

JOINT EXAMINATION

 Read the question carefully. It could go as follows:

 Examine the joints of this patient

 Examine the joints of the lower limb of this patient

 Examine the knees of this patient

 Examine the hand joints of this patient

Let us assume the question is ‘examine the joints of this patient’

 Greet the examiner

 More straight to the right side of the patient

 Greet the patient, introduce yourself, allay his fears and obtain consent

 Screen the patient or pretend as if you want to screen if he is already screened.

 Apply hand sanitizer

 Ensure adequate exposure

 Joint examination can be done in sitting or supine position, at least for the purpose of this

exam.

 Ask if the patient is feeling pain in any joint

 Examine almost all the joints from the head to the toe

 The general principles are

1) Inspect: looking for swelling, erythema deformity, sinuses, scars (previous joint

replacement)

2) Feel: palpate for tenderness. Feel for differential warmth

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 3) Move the joint. Ask the patient to move the joint then you move the joint later

 Be mindful of tenderness and limit of motion

 Start from the head

 Look at the temporomandibular joint. Palpate for tenderness

 Ask the patient to open his mouth with your hands on the temporomandibular joint and then,

close the mouth

 Look at the neck, palpate for tenderness

 Ask patient to flex and extend the neck. Then, tell him to do right lateral flexion and left

lateral flexion

 Move to the upper limb

 Ask if there is pain in the shoulder

 Look for erythema or swelling

 Ask patient (while you demonstrate it) to flex, extend, abduct and adduct the

shoulder

 Move it gently to determine the limit of motion

 Move right shoulder with your right hand while your left hand is applied on the

shoulder to feel for crepitus.

 Do the same for the left shoulder

 Look at the elbow joint

 Palpate for tenderness

 Let the patient flex and extend the elbow

 You can flex the right elbow with your right hand which your left hand is on the

elbow posteriorly to feel for crepitus.

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  Do the same for the left elbow.

 Ask the patient to stretch forth the hands

 Ask if there is any pain

 Look at the palms and the dorsum

 Look for deformities or nodes

 Palpate for tenderness

 Gently squeeze each hand one by one

 Ask the patient if he could stand unsupported if you tell him to stand.

 Ask the patient politely to stand up

 Look at the spine for deformities (scoliosis, kyphosis and so on)

 Palpate the whole of the spine for tenderness

 Ask the patient (while you demonstrate the movement for him) to flex the spine

so as to touch to the toes with the fingers without bending the knees.

 Ask the patient to extend the spine as far as possible

 Ask the patient to do lateral flexion of the spine on each side

 Ask the patient to rotate the spine (by gently twisting the spine to each side)

 You need to demonstrate the movements for the patient (assuming you are fine

too!)

 Observe tenderness on movement and the limit of movement

 While still standing, ask him to walk so as to examine the gait.

 Then ask the patient to sit or preferably lie down

 Palpate the trochanteric areas for tenderness

 Move the hip actively and passively

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 Examine the knee joints

 Observe the knee for deformities (genu valga, genu vara and so on)

 Look for swelling, erythema, scars and so on

 Palpate for tenderness

 Ask the patient to flex and extend the knees

 Active flexion and extension of the knees

 Feel for crepitus

 Examine the ankle and the foot joints

 Inspect the ankle and the heel

 Look for erythema and swelling

 Move actively and passively

 Squeeze the feet gently for tender

 Examine the big toe for swelling or erythema. Palpate for tenderness. Move

actively and passively

PRESENTATION OF EXAMINATION FINDINGS

Your presentation will go as follows:

Good morning Sir/Ma,

I have examined the joints of this elderly woman. The main findings are in the knees.

There are genu vara. The knees are swollen. No erythema was seen. It was tender but there was

no differential warmth. There was significant limitation of extension and flexion due to pain.

Crepitus was felt bilaterally.

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FORMULATION OF DIFFERENTIALS

This is technical because it depends on the patient before you. So, you need to open your mind.

The following suggestion are not exhaustive but helpful.

You need to summarize the joint pathology into one of the following.

 Monoarticular arthritis

Differentials are: 1. Osteoarthritis

2. Septic arthritis

3. Gouty arthritis

4. Pseudogout

5. Traumatic

 Symmetric oligo or polyarthritis

Differentials are:

1. Rheumatoid arthritis

2. Psoriatic arthritis

3. Reactive arthritis

4. Systemic lupus erythematosus (young lady in reproductive age

group)

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 CHAPTER EIGHT

SKIN EXAMINATION

 Read the question very well

 It may be specific or generalized

 Examine the face of this patient

 Examine the skin of the patient

 Examine the hands and feet of this patient

 Examine the legs of this patient

Whichever one is asked, it is the same thing, the only difference is the emphasis.

Come with your magnifying lens. It impresses some examiners.

 Greet the examiner

 Proceed to the right side of the patient

 Greet the patient

 Introduce yourself, allay her fears and obtain consent.

 Expose the patient adequately.

 Politely request that she removes her head gear (be sensitive to some people’s religious belief

in head covering).

 Apply your hand sanitizer

 If you are told to look at a specific area, go to that area first e.g. face.

 If not specifically stated, examine from head to toe looking for the rash.

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 Rule of thumb: usually, the rash is in a relatively obvious area. By the time you are asking

that the patient should remove the underwear still looking for the lesion, you have most likely

missed the lesion!

 Note the type of the lesion

 Primary lesion: hyperpigmentation or hypopigmentation, macules, papule, patch

 Secondary lesion: lichenification, scars, ulceration, fissure, excoriation.

 Note the distribution: e.g. exposed areas of hand and face

 Note the arrangement of the lesion e.g. linear, annular

 Examine with the magnifying lens

 After examining the rash carefully, examine the scalp, the mouth, the finger nails and toe

nails.

 Thank the patient and cover him up

 Thank your examiner

 Apply the hand sanitizer

 Present your finding

PRESENTATION OF EXAMINATION FINDINGS

Your presentation will go as follows:

I have examined the skin of this young lady. I found some papules with comedones on the face.

The face also appeared to have seborrhoea. There were some hyperpigmented macules on the

face and some papules were also seen on the upper anterior chest.

The scalp hair was intact. No significant lesion in the mouth and the nails were essentially

normal. No other lesion was seen in any other part of the body

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FORMULATION OF DIFFERENTIALS

This is usually very challenging. Some of the following tips may be helpful.

 Differential diagnoses of papules on the face include:

1. Acne vulgaris

2. Acneiform drug eruptions

3. Folliculid

4. Rosacea

5. Syringoma

6. Adenoma sebaceum

 Differential diagnoses of hypopigmented/depigmented patch/macule

1. Vitiligo

2. Leukodema (drug induced)

3. Pityriasis versicolor

4. Pityriasis alba

5. Hansen’s disease

6. Idiopathic guttate hypomelanosis

 Differential diagnoses of hyperpigmented/depigmented patch/macule

1. Fixed drug eruptions

2. Café au lait spots (neurofibromatosis)

3. Ochronosis

4. Melasma

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 Differential diagnoses of generalized hyperpigmentation

1. Addison’s disease

2. Cushing’s syndrome

3. Coeliac disease

4. Haemochromatosis

5. Nelson’s disease

6. Hyperthyroidism

 Differential diagnoses of scaly papules and plaques

1. Lichen planus

2. Lichenoid drug eruptions

3. Psoriasis

4. Lichen simplex chronicus

5. Tinea corporis

 Differential diagnoses of localized alopecia

1. Alopecia areata

2. Tinea capitis

3. Lichen planopilaris

4. Discoid lupus erythematosus

5. Trichotillomania

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 REFERENCES

1. Andrew R. Houghton and David Gray. CHAMBERLAIN’S Symptoms and Signs in

Clinical Medicine: An Introduction to Medical Diagnosis. Edward Arnold (Publishers)

Ltd; 13th Edition 2010

2. Jonathan Gleadle. History and examination at a glance Blackwell Science, 2003

3. Micheal Swash and Micheal Glynn. Hutchison’s clinical methods an integrated approach

to clinical practice edited by Saunders publishers; twenty-fourth edition, 2017

4. Paul D. Chan and Peter J. Winkle. Current Clinical Strategies History and Physical

Examination. Current Clinical Strategies Publishing Tenth Edition 2006

5. Professional Guide to Signs and Symptoms, Lippincott Williams & Wilkins; fifth Edition

2007

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