General 

Mental state; personal care; features; clinical syndromes; posture

Pulse, blood pressure, respiratory rate, temperature

Hands: skin (palm and dorsum) color, temperature, moisture, palmer erythema, cyanosis, staining (nicotine, bruising, rashes), pigmentation, tone, thickness, laxity, senile changes Oslers nodes, rheumatoid changes, Dupuytren’s contracture

Nails: bitten, pallor, spooned, clubbing, splinter hemorrhages

Muscles: wasting, abnormal movements, flap

Lymphadenopathy

Head and Neck

Cranial Nerves:

I: smell
II: visual acuity, color vision, visual fields, fundoscopy
III,IV,VI: pupillary responses to light and accommodation, extraocular movements, ptosis, lid lag, nystagmus, enophthalmus, exophthalmos
V: sensation over the three divisions; corneal reflex, muscles of mastication, jaw jerk
VII: facial expression, whistle, blowing out cheeks against resistance, taste anterior two-thirds tongue
VIII: hearing: watch, whisper, Rinne’s and Weber’s tests IX: gag reflex, taste posterior third tongue
X: voice, cough, uvular deviation, swallow
XI: shoulder shrugging, neck rotation, head nodding XII: tongue movements
Nose: deformity, airway, bleeding

Eye: Conjunctiva: inflammation, chemosis, pallor, subconjunctival hemorrhage

Sclera: red, yellow, blue, brown

Cornea/lens/iris: scars, abrasions, ulcer, cataract, arcus senilis, sclerolimbic calcification, coloboma
Exophthalmos, enophthalmos, glaucoma
Movements: extraocular movements, conjugate in all directions, nystagmus, fatigability of pursuit movements
Visual fields: to confrontation with finger, and white and red pin heads
Visual acuity: Snellen’s chart, reading chart, light and accommodation reflexes, Horner’s syndrome
Fundi: optic disc, vessels, macula
Ear: Pinna: malformation, gouty tophi
External acoustic meatus: wax, infection
Tympanic membrane: scarring, redness, perforation, bulging (and Valsalva)
Hearing: watch, whisper, Rinne’s and Weber’s tests
Temporomandibular joint: movements

Mouth:

Lips: telangiectasia, swelling, ulceration, pigmentation, Koplik’s spots, cleft

Gums: gingivitis, hypertrophy, retraction

Teeth: discolouration, caries, periodontal disease

Tongue: glossitis, atrophy, macroglossia, geographic tongue, ulceration, leukoplakia, neoplasia

Tonsil: redness, purulent discharge, gag reflex

Oropharynx: redness, coated, purulent discharge, fetor

Salivary glands: tenderness, swelling, abscess, cysts, tumors, duct calculi

Face: 

Congenital features, Cushing’s, acromegaly

Facial palsy: upper/lower motor neurone

Cachexia, weight loss, edema

Neck: 

Trachea: deviation, tug

Thyroid: palpable, enlarged, symmetrical, focal lump, cyst, benign, malignant tumours, tracheal deviation, retrosternal extension, bruit, movement on swallowing

Carotid arteries: enlargement, bruits, jugular venous pressure, hepatojugular reflex

Lymph nodes: submental, submandibular, preauricular, postauricular, occipital, deep and superficial cervical lymph chains

Neck movements

Musculoskeletal System 

History: localise symptomatic muscles, joints, bones

Pain, stiffness, limited movement, creaking, cracking, locking, giving way, swelling, wasting, contractures, deformities, loss of function

Manual dexterity: dressing, toiletry, eating, writing

Mobility: ability to sit and stand, walking distance, independence, need for assistance or mechanical aids, work and recreational activity

Symptoms of inflammatory disorders: fever, malaise, ocular problems, urethritis, diarrhea

Examination: pain at rest/on movement, Cushingoid, Paget’s deformity, weight, fever, malaise, inflammatory eye conditions, blue sclera, gouty tophi, digital trophic changes

Nails: color, discolouration, pitting, ridging, hyperkeratosis

Compare bones, joints and muscles of the two sides of the body. Ensure appropriate exposure and record any abnormalities of asymptomatic joints

Look: skin: creases, scars, color, erythema, atrophy, rashes, sinuses

Shape: swelling of bone, bursae, synovium, effusions, bony alignment (valgus/varus), subluxation, dislocation, shortening, deformity, wasting

Position: at rest and during activity

Hand deformities: swan neck, boutonnier’s, z thumb, finger drop, mallet finger, Dupuytren’s contracture, Heberden/Bouchard nodes, ulnar deviation

Posture: kyphoscoliosis, neurological and myopathic abnormalities, Trendelenburg test

Feel: skin, soft tissue and bones, warmth, tenderness, thickening, nodules, overgrowth, deformity

Abnormal bursae/synovial thickening

Effusions: reducible, fluctuant, ballottable, transillumination

Fractures: tenderness, deformity

Move: active, passive and resisted movements in each joint plane

Pain, power, tone, range, creaking, crepitus, clicking, triggering, locking, hypermobility, telescoping, contractures, stability

Fracture: abnormal mobility, crepitus.

Deformity: mobile or fixed

Hand: ability to grip, pinch and do up shirt buttons

Gait: spastic, ataxic, waddling, limp, use of mechanical aids

Measure: range of joint movements (goniometer)

Limb circumference at equivalent levels from fixed bony points on the limbs on each side

True and apparent leg shortening, Bryant’s triangle

Proceed to X-ray and image symptomatic areas, to identify abnormal bone and soft tissues

Female Breast

History: Pain: cyclical/persistent

Lump: generalized/discrete, duration, change, previous history

Discharge: milk, pus, blood, serous (color)

Menstrual history: pregnancy, breast feeding, pill and hormone replacement

Family history

Examination: secluded, warm area with subject undressed to waist

Sitting, reaching up, leaning forward, lying

For each breast: pillow behind shoulder and hand behind head

Look for: symmetry, mobility, flattening, swelling, skin dimpling, redness, peau d’orange, ulceration, submammary edema, lumps

Palpate: each quadrant, the retroareolar area and the nipple, for nodularity (general/focal), lumps, mobility

Express from the nipple

Axillary nodes: anterior, medial, posterior, lateral, apical, infraclavicular, supraclavicular

Liver enlargement, spinal tenderness

Cardiovascular System

History: Pain: angina, central chest (radiation), back

Palpitations, edema, cyanosis, fatigue, syncope

Cough, sputum, hemoptysis; dyspnea, orthopnea, paroxysmal nocturnal dyspnea

Hypertension, diabetes, hypercholesterolemia, smoking, family history of vascular disease

Symptoms of stroke: visual, speech, motor, sensory, cranial and peripheral nerves, memory

Claudication, pain in feet at rest, foot ulceration, gangrene

Examination: Marfan’s, Down’s, Turner’s syndromes, cachexia

Hands, fingers and nails: clubbing, peripheral cyanosis, nicotine staining, splinter hemorrhages, Osler’s nodes

Head and neck: jugular venous pressure (cannon waves, CV systolic waves), hepatojugular reflex, xanthelasma, pallor, jaundice, central cyanosis, malar flush, fundi

Arterial pulse: rate, rhythm, volume, character, thickening of vessel wall

Tachycardia, bradycardia, sinus arrhythmia, premature beats, atrial fibrillation, hyperdynamic, collapsing (Corrigan), bisferiens alternans, pulsus pardoxus

Radio-femoral delay, radial asymmetry, cardio-peripheral deficit

Peripheral pulses: presence, symmetry, volume, bruits

Blood pressure: standing/lying

Respiratory rate, temperature

Heart: lying at 45 degrees, repeated in supine, rotated and sitting positions, on to Valsalva and squatting manoeuvres

Position, force and character of apex beat, abnormal pulsaton, thrills, cardiac outline, scars

Auscultation with bell and diaphragm over mitral, aortic, pulmonary and tricuspid areas, repeat during inspiration and expiration, and appropriate positions

Sounds: first and second, splitting, third and fourth, summation gallop, opening snap, ejection click, mid/late systolic click, pericardial knock/rub

Timing of onset and offset of murmurs in relation to systoli, diastoli and valve closure, point of maximum intensity, grade, radiation, effect of positional and respiratory manoeuvers

Systolic: aortic stenosis, HOCM, mitral regurgitation, mitral valve prolapse, ventricular septal defect

Diastolic: aortic regurgitation, mitral stenosis

Continuous: patent ductus arteriosus, venous hum, pulmonary arteriovenous malformation, ruptured coronary sinus

Lungs for basal crepitations, pulmonary effusion

Hepatomegaly, liver pulsation, ascites, peripheral edema

Feet: pulses, trophic changes, pressure sores, ulceration, gangrene, inflammation, abscess formation, neuropathy, postural changes, venous filling time

Respiratory System 

History: upper respiratory tract infection, nasal discharge, nasal obstruction, pain over sinus or in ears, cervical lymphadenopathy

Chest pain: related to respiration, angina

Cough: day/night time, dry, productive, sputum (appearance and volume), hemoptysis

Breathlessness: at rest, on exercise, orthopnea, paroxysmal nocturnal dyspnea, wheezing

Pyrexia, rigors, cyanosis, edema, myalgia

Examination: cough, sputum (examine sputum pot: colour, consistency, volume)

Pulse, blood pressure, respiratory rate, temperature

Hands, fingers and nails: clubbing; peripheral cyanosis, nicotine staining, wasting of small muscles, wrist tenderness, carbon dioxide retention flap

Head and neck: conjunctival pallor, jugular venous pressure, Horner’s syndrome, hoarseness of voice

Cervical and axillary nodes

Chest: pattern of respiration, rate, depth, tachypnea, dyspnea, irregularity, stridor, use of accessory muscles, Cheyne-Stokes

Anterior chest wall configuration: pectus excavatum, pectus carinatum

Scars, prominent veins

Vertebral column abnormalities: buffalo hump, barrel chest, lordosis, kyphoscoliosis

Palpate tracheal deviation, tracheal tug

Chest expansion: manual assessment and tape measure

Tactile vocal fremitus, subcutaneous emphysema, rib tenderness

Percussion: resonant, hyper-resonant, dull, stony dull

Coarse percussion.

Auscultation: use bell and diaphragm

Breath sounds: normal, vesicular, bronchial, bronchovesicular

Adventitious sounds: crackles (râles), wheezes (rhonchi)

Vocal resonance: egophony, whispering pectoriloquy

Pleural friction rub

Alimentary and Genitourinary Systems

History: weight (current, changes), fatigue, pigmentation

Pain: site, radiation, relation to food

Flatulence, nausea, vomiting, hematemesis

Dysphagia: site, solids/fluids

Stool: frequency, quantity, consistency, mucus, blood (fresh, altered, melena), tenesmus

Perianal pain; lump, discharge, pruritus

Micturition: frequency, nocturia, polyuria, oliguria, hematuria, obstruction, hesitancy, poor stream, dribbling, urgency, dysuria

Urethral discharge/pain

Urine: amount, discoloration, clarity, color, blood, debris

Menstruation: menarche, menopause, dysmenorrhea, menorrhagia, amenorrhea

Dyspareunia: superficial/deep, vaginal discharge, contraception

Pregnancy: past obstetric history, last smear, last menstrual period, expected date of delivery, abdominal pain, vaginal bleeding, venous thrombosis

Examination: presence and features of any vomitus

Weight loss, cachexia, dehydration, obesity, hypo/hyper pigmentation, encephalopathy

Hands: palmer erythema, telangiectasia, Dupuytren’s contracture, skin laxity, muscle wasting, arthropathy, liver flap

Nails: pallor, clubbing, spooning, leukonychia, onycholysis

Head and neck: conjunctival pallor, jaundice, xanthelasma, halitosis (hepatic, uremic, faecal, ketotic), tongue (dry, furred, glossitis, leukoplakia), gingivitis, dentition

Salivary glands: tenderness, swelling

Cervical lymphadenopathy (NB: scalene node)

Abdomen: lying supine with a single pillow, fully exposed, but breasts and genitalia covered until these areas are examined

On inspection: skin: laxity, pigmentation, bruising, scratch marks, stria, hair distribution, scars, sinuses, fistulas, stomas, dilated veins, herniae, divarication of the recti

Umbilicus: position, hygiene, nodules, discharge, hernia

Distension: scaphoid abdomen, respiratory movements, visible peristalsis

Enlarged organs: liver, gall bladder, spleen, bladder, uterus, masses

Discomfort on blowing out/drawing in abdominal wall and coughing

On percussion of the four quadrants: rebound tenderness, hyper- resonance, position of organs (liver, spleen, bladder, uterus), masses, ascites, shifting dullness

On palpation: NB: watch patient’s face throughout. In children and with sensitive abdomens, start with self-examination to identify tender areas

Superficial/deep four quadrant, tenderness, guarding, rigidity

Organs: liver, gall bladder, spleen, kidneys, bladder, uterus, colon/faeces

Masses: stomach, pancreas, uterus, ovarian, large/small bowel, retroperitoneal

Aorto-iliac aneurysms

Ballottable organs/masses, fluid thrill, sacral edema

On auscultation: gut sounds: normal, absent, tinkling, increased

Friction rub

Renal, aorto-iliac bruits/hums

Succussion splash

Inguinal/Femoral Hernia

If not obvious ask the patient to stand

Observe site, overlying skin, cough impulse, reduction by patient

Palpate for tenderness, cough impulse, reducibility, anatomical position of neck, controllability

Inguinal/axillary nodes

External Genitalia

Draw scrotum forward onto the front of the thighs

Observe symmetry, skin, scars, rashes

Swellings: inguino-scrotal, scrotal (testis, epididymis)

Palpate: testis, epididymis, spermatic cord

Relation of cyst/masses to testis/epididymis

Penis: circumcised, retractable foreskin, position and shape of meatus, balanitis, discharge

Rectal/Vaginal examination

Nervous System 

History: current mental state: level of consciousness, orientation, memory (recent, long term), intellect, understanding, insight, thought content, behaviour, mood, hallucinations, delusions

Prior injury, stroke, transient ischemic attack

Headache, fits, faints, falls, dizziness

Disturbances of vision/speech, diplopia, visual loss, dysarthria, dysphasia, aphasia

Disturbances of motor or sensory function of limbs/face, dysesthesia, clumsiness, weakness

Examination: NB: compare the two sides of the body

Handedness

Speech: dysphasia (expressive, receptive, global), jargon, scanning, stuttering, dysarthria

Motor function: tone: spasticity, flaccidity, rigidity, clonus

Power: hand grips, wrists, elbows, shoulder, ankles, knees, hips

Coordination finger-nose, heel-shin, dysdiadochokinesis, pyramidal drift

Reflexes: tendon, superficial

Abnormal movements: tremor (static, intention), choreiform, athetoid, convulsions, associated movements, tics

Muscle: wasting, hypertrophy, fasciculation

Abnormalities of posture: upper/lower motor neurone, extrapyramidal, cerebellar, sensory, myopathic, Romberg’s sign, standing on toes, walking backwards on heels, heel-toe

Gait: spastic, ataxic, waddling, limp

Sensory function: nerve root, spinal cord level, hemianesthesia

Light touch: cotton wool

Pain: pinprick

Temperature: finger/tuning fork

Vibration: start distally on wrist and ankle

Position sense: hold sides of digit

Graphesthesia: use threes and eights

Two-point discrimination: blunt compass, start on hand

Stereognosis: coins, keys

Spinal deformity/tenderness, neck rigidity

Palpate and percuss abnormal superficial nerves

Map out areas of altered sensation

Contractures, neuropathic joints, ulceration

Carotid bruits

Autonomic: sweating, postural hypotension, heart rate response to a Valsalva manoeuvre