1 
ENT HEAD AND NECK
CLINICAL EXAMINATION
Examination of theThyroid
NEUROLOGIC EXAMINATION
Cranial Nerve Examination
‐ Inspection: scar marks, asymmetry of face, eyes,
pupils, wasting
‐ I – ask patient to smell
‐ II – PEARL, Funduscopy, VA, pinhole test, visual
fields,
‐ III, IV, VI – ptosis; presence of asymmetry of eyes and
pupils; extraocular movements; accommodation
‐ V – sensation (ophthalmic, maxillary, and mandibular)
and motor (clench teeth - masseter; open mouth and
push to close – pterygoid muscles; if weakened jaw
deviates to affected side); corneal reflex; jaw jerk
(UMN)
‐ VII – close eyes and don’t let me open them, smile,
wrinkle forehead, puff up cheeks
‐ VIII – whisper test; rinne test and weber (256)
‐ IX and X – hoarseness; cough; ask to sip water to
check problems with swallowing; Gag reflex and uvula
‐ XI – raise shoulder and SCM
‐ XII – tongue
TIA Examination
‐ Face: asymmetry of face, ptosis, eyes/pupil of equal
size, redness/swelling; PEARL; ophthalmoplegia;
accommodation; funduscopy
‐ JVP, carotid pulse and bruit
‐ Upper/Lower limb neurologic examination
Neurological Examination of the Upper Limb
‐ Inspection: signs of head injury, facial asymmetry,
ptosis, muscle wasting and fasciculation
‐ Palpate muscles for tenderness, Pronator drift
(UMN/cerebellar lesion), tremors,
‐ Tone
‐ Power (shoulder grasp, biceps and triceps power,
flexion and extension of wrist, grasp, flexion and
extension of fingers; adduction and abduction of
fingers
‐ Reflexes: biceps, triceps, brachioradialis
‐ Sensation
‐ Vibration and Proprioception
‐ Finger-to-nose test and alternating movements
(dysdiadochokinesia)
Neurological Examination of the Lower Limb
‐ Inspection: wasting of muscles, tremors,
fasciculations, surgery marks, deformity
‐ Gait assessment: observe for limping
‐ Walk on heels: L5
‐ Walk on toes: S1
‐ Squatting
‐ Romberg test
‐ Heel-Toe Walking
‐ Palpation for tenderness of muscles
‐ Power (hip flexion and extension, knee flexion and
extension, adduction, abduction, inversion, eversion,
plantar flexion, dorsiflexion)
‐ Reflexes (knee, ankle, babinski, clonus)
‐ Sensation
‐ Vibration and Proprioception
‐ Cerebellar: Heel-to-shin, foot tapping test
- IF you feel any pain or discomfort during the
examination, please let me know and I will stop. I will
be gentle.
- Ask patient to remove clothing and wash hands!
- Inspection:
o General appearance: appropriate dressed
for the weather
ƒ hyperthyroidism:
anxious/restless/agitated, weight
loss
ƒ hypothyroidism:
depressed/sad/dull/apathic/anxiou
s/restless/agitated/ hoarse
voice/sluggish
o Neck: look for swelling, scar marks, dilated
veins (retrosternal extension), redness
(thyroiditis)
o Ask patient to sip water and look for
movement during deglutition; check border;
ask patient to protrude tongue
- MASS: 4S (site, size, shape, suface), 4C (color,
consistency, contour, compressibility), 3T
(temperature, tenderness, transillumination), 2F
Fluctuation, Fixation), pulsatile, reducible, signs of
inflammation
- Palpation (from behind)
o Palpate both lobes and isthmus
o Sip of water and look for all characteristics
of the mass (soft: adenoma; cystic: cyst;
firm: goiter; hard: cancer; tenderness:
thyroiditis; immobile: cancer); palpable thrill
o Cervical lymph nodes (submental –
submandibular – preauricular –
postauricular – anterior cervical – posterior
cervical – occipital)
o Look at position of trachea from front (if
displaced may be retrosternal extension)
- Percussion: from upper part of manubrium from one
side to the other (change from resonant to dull
indicates restrosternal goiter)
- Auscultation: listen for each lobe for any bruit
(increased blood supply due to hyperthyroidism)
- Pemberton sign: ask patient to lift both arms as high
as possible and look for plethora, cyanosis, respiratory
distress, or neck vein distention Æ signifies thyroid
gland is closing the thoracic inlet and impedes venous
flow to the heart
- Hands, nails and skin
o Hyperthyroidism: warm, sweaty, palmar
erythema; onycholysis (nail separating from
bed); tremors; shiny and smooth
o Hypothyroidism: cold, dry, swollen, thick
skin, anemia; dry and coarse
- Pulse for rate and rhythm and Blood pressure
- Reflexes
o Hyperthyroidism: brisk reflexes
o Hypothyroidism: delayed relaxation
- Proximal myopathy: hyperthyroidism
- Face
o Hyperthyroidism: fine shiny hair, proptosis,
lid lag and retraction, chemosis (edema of
conjunctiva), conjunctivitis, corneal
ulceration, ophthalmoplegia

o Hypothyroidism: brittle, dry and coarse,
alopecia, loss of eyebrows, periorbital
edema, facial puffiness, xanthelasma (lipid
deposits over the lower eyelids), swollen
tongue
- Other signs (Hypocalcemia):
o Schvostek: twitching of facial muscles upon
tapping of the facial nerve along the angle of
the mandible
o Trousseau: flexion of wrist and MCP joints
upon inflating the BP cuff above systolic.
- Chest: gynecomastia in hyperthyroidism; pleural
effusion (hypothyroidism)
- CVS: hyperdynamic circulation (arrhythmia and
cardiac failure) and systolic flow murmurs; pericardial
effusion (hypothyroidism)
- Myopathy: sit and stand Æhyperthyroidism
- Legs: pretibial myxedema (bilateral firm, elevated,
dermal nodules on the shin, may be of different colors
– hyperthyroidism
Examination of a Patient with Facial Trauma
- Ask for consent
- Inspection (Look): there is a bruise on the left side of
the cheek; no obvious asymmetry or swelling is noted;
no obvious fracturers; in the eyes there is no raccoon
eyes (purplish discoloration around the eyes: orbital
floor fracture) or any swelling or redness; on the nose
there is no obvious fracture; no obvious drainage of
fluid. Ask patient to open the mouth and look for any
loss of tooth or injury. On the ears look for any injury,
bleeding, or fluid. There is no battle sign (discoloration
of mastoid due to basal skull fracture) On the neck
and head, there is no obvious swellings, bumps,
deformities
- Feel: feel surrounding area for fracture or tenderness;
take torch to look for pupillary light reflex; do EOM
(diplopia); ask for funduscopy and visual acuity; take
pin to check for sensation; clench teeth; corneal reflex;
close eyes and do not let patient open them; open
teeth and smile for me; feel head for any injury or
swelling; feel cervical spine and paraspinal muslces to
look for tenderness;
- Move: do ROM of neck;
Pleiomorphic Adenoma
Case: A middle-aged man comes in to your GP clinic with a
swelling on the left side of his face just above the angle of his
jaw between the mastoid and mandible. A picture of the swelling
is provided.
Task
a. History (lump x 5 years noticed when he was shaving;
slowly growing, not painful, came in due to cosmetic
reasons, + smoker x1/2 pack)
b. Physical examination (3x3, irregular, firm, nontender,
rounded/bosselated, well-circumscribed, no punctum,
redness, discharge or scar marks, no LN enlargement,
facial nerve examination)
c. Diagnosis and management
History
‐ Can you tell me more about it? When? Is it growing
suddenly or slowly? Painful or not painful? Does it
move when you feel it? It is firm or hard when you feel
it? Any ulceration, infection or bleeding from this site?
Any other lumps and bumps in the body? Any weight
loss or change in appetite? Did you notice any
2 
asymmetry of the face? Any disturbance in function of
your face? Any change in taste sensation? Any
problems with swallowing, hearing or breathing?
Hoarseness? do you have any pain or swelling in the
gum while chewing?
‐ How is your general health?
‐ PMHx of cancer or radiation therapy?
‐ FHx of cancer
‐ SADMA?
Physical examination
‐ General appearance
‐ Vital signs
‐ ENT: Inspection, palpation (site, size, shape, surface,
contour, consistency, compressibility, temperature,
tenderness, transillumination, fixation, fluctuation,
reducible, pulsatile, signs of inflammation, discharge,
ulceration, vascularity), Lymph nodes (submandibular,
submental, anterior and posterior auricular, occipital,
anterior and deep cervical LN), Facial nerve testing:
asymmetry, close eyes and don’t allow to open them,
smile, clench teeth, Do check oral cavity using mouth
and torch (dental problem or ulcers of mouth and
tongue); parotid duct:: palpate from inside of the
mouth and check for discharge and salivary stone
Diagnosis and Management
‐ For examiner: We are presented with a middle-aged
man who presents with a long-standing mass on the
face which is suggestive of a parotid enlargement. On
examination, the mass is noted to be well-
circumscribed firm mass without signs of facial nerve
involvement which is highly suggestive of a benign
tumor called pleiomorphic adenoma.
‐ For patient: From history and examination you have a
condition called pleiomorphic adenoma of the parotid
gland. Let me assure that it is a benign swelling and to
further confirm it, I will refer you to the surgeon. He will
do a CT scan or MRI to see the overall dimension and
tissue invasion and FNAC to determine whether the
tumor is benign or malignant.
‐ Differential Diagnosis: Warthin’s tumor, Sebaceous
cyst, lymphoma, metastasis from primary growth,
parotid abscess, lipoma, pre-auricular adenoma,
Chronic parotitis
‐ Once confirmed the surgeon will remove it through a
procedure called Superficial parotidectomy. In this
surgery, the lump is removed and the facial nerve is
preserved. Complications include: hemorrhage,
anesthetic complications (aspiration), facial nerve
injury, salivary fistula, recurrence
‐ Reading materials, refer and review.
‐ For cancer: Total parotidectomy or block neck
dissection with radiotherapy
RESPIRATORY SYSTEM EXAMINATION
Examination of the Respiratory System
- Consent
- Inspection: sitting comfortably on the bed and does
not appear to be SOB, conscious and alert, not
cyanosed, not attached to oxygen, no medications, or
IV lines. He does not appear cachectic.
- Hands: cyanosis, clubbing, nicotine stains, test
patient's resistance to adduction (brachial plexus
involvement in pancoast/apical lung tumor), press
wrist and note tenderness (hypertrophic pulmonary
osteoarthropathy - results from periosteal
 3 
 
inflammation secondary to pancoast tumor), pulse and o Auscultation: bell of stethoscope at apex
RR, wrist extension for 30 mins and look for flapping beat;
tremors for CO retention

- Face: pallor, jaundice, Horner syndrome, check for ƒ MS: mid-diastolic (bell); ask
tenderness of maxillary and frontal sinuses, nose for patient to turn on left side Æ feel
swelling, polyps, and deviated nasal septum, open hand for palpable thrill; auscultate
mouth to check for focus of infection, speak a murmur heard clearly;
sentence for hoarseness, ask px to cough for bovine ƒ MR: pansystolic (diaphragm);
cough radiates to axilla;
ƒ AS: ejection systolic murmur;
- Neck: Lymph node and trachea, JVP (if indicated) Neck;
ƒ AR: early diastolic murmur; ask
Chest patient to lean forward; then
- Inspection: pectus carinatum/excavatum, deformities, breathe in and out Æ hand and
scars, radiation marks, erythema and signs of auscultate
inflammation, tattoos, barrel-shaped chest, ƒ Systolic murmurs: radiate
kyphoscoliosis, spine central ƒ Diastolic murmurs: accentuated by
- Palpation: check chest expansion (breathe in and out change of position
by mouth): upper lobe expansion (equal rising of ƒ Dynamic auscultation: Pinch nose
clavicles), middle and lower lobe: thumbs should and ask patient to breathe in and
move at least 5cm, sacral edema, tactile fremitus (with try to breath out thru the ears
hands over chest) valsalva Æ auscultate at left
- Percussion: supraclavicular area sternal edge for systolic murmur of
- Auscultation: air entry, added sounds, vocal fremitus HOCM
Examine anterior chest as well - Back:
o Inspect: scars, deformity, bamboo spine
- Do Peak expiratory flow rate (PEFR) (PR)
o F: 400L/min and M: 600L/min o Feel: sacral edema, pleural effusion
o Auscultation: crepitation, pleural effusion (no
CARDIOVASCULAR AND PERIPHERAL VASCULAR breath sound)
o Radiofemoral delay: listen to scapula Æ
Cardiovascular Examination COA
- Position patient to 45 degrees and expose neck and - Abdomen: lying flat with one pillow
chest up to lower abdomen o Abdomino-jugular reflex
- General inspection: lying comfortably at 45 degrees, o Palpate liver and spleen
not cyanosed and dyspneic, not cachectic (cardiac o Ascites
cachexia Æ weight loss due to heart failure), no o Aortic aneursym
features of down, marfan, turner syndrome, not - Lower limbs for edema, pulse
attached to oxygen, ECG monitor or drugs on the side - Urine dipstick, funduscopic, hematuria, HTN changes,
of the patient Roth spots in infective endocarditis
- Hands/nails: check for cyanosis, splinter
hemorrhages, clubbing, CRT, nicotine stains, palmar Murmurs:
erythema, Janeway lesions (painless red macular - MS: normal pulse, reduce in volume
patches on palms), Osler nodes (tender nodules on - MR: pounding pulse
the pulp of the fingers), anemia/pallor, tendon - AS: slow-rising pulse
xathomas - AR: collapse pulse
- Arms: Radial artery pulse for rate and rhythm,
compare both pulses for Radioradial delay (subclavian Systolic murmur at aortic area (DDx)
artery stenosis) or Radiofemoral delay (COA), - AS radiate to carotid
collapse impulse (AR), BP (sitting and standing) - Aortic Sclerosis (doesn’t radiate)
- Face: anemia, jaundice, xanthelasma, malar flush - HOCM functional systolic murmur
(SLE, MS, pulmonary stenosis), tongue and lip for - Pregnancy
central cyanosis, high-arched palate (marfan - Thyrotoxicosis
syndrome), petechia, telangiectasia (IE), - Fever
stomatitis/gingivitis; - Anemia
- Neck: carotid pulse, JVP (patient at 45 degrees: use 2
ruler: 1 ruler straight up at manubrio-sternal angle Main causes of AS
then measure in cm Æ add 5cm Æ >8cm is raised - Increased age
JVP) - Congenital bicuspid valve
- Precordium:
o Inspection: scars (middle Main causes of MR
sternotomy/thoracotomy), pacemaker - Rheumatic fever
(below clavicle, subcutaneous), - MVP/rupture of chordate tendinae
kyphoscoliosis, pulsations, deformity - MI
o Palpation: apex beat (5th mleft ICS, 1cm - Infective endocarditis
medial to the midclavicular line; check - Dilated cardiomyopathy
whether
forceful/tapping/displaced/diffuse/parasterna
l impulse), heave (palm), thrill at base of
heart (pulmonary and aortic area Æ using
fingers)

Examination of the Lower Extremities
- Introduce yourself. I understand from your notes that
you’re having pain on the leg. My task is to do the
physical examination. During this examination, I will
look and will be palpating/feeling some parts of the
leg. I will also need to listen to some of the vessels on
your leg with the use of my stethoscope.
- AT this moment I would like to ask you if you have any
pain. I will ask for your permission to expose your
thighs and legs (usually up to the nipple area but
cover abdomen and expose only when required).
While you undress I would just like to wash my hands.
- Inspection:
o Abdomen: check for visible pulsation (AAA –
left of the midline), scar marks;
o Groin: pulsation, scar marks;
o thigh and legs: muscle wasting, joint
deformities, atrophy of the skin, loss of hair,
change of color of skin, shiny skin;
o feet: obvious deformity, ulcers (include toes,
raise legs, under heels), hallus valgus;
discoloration/cyanosis/blackening of nails;
look for signs of amputation in toes; obvious
edema and signs of inflammation
- Palpation: check for capillary refill time (<3secs); feel
for temperature (with dorsum of hands); pinch shins
for any edema; feel the PULSES (dorsalis pedis,
posterior tibial, popliteal, femoral, abdomen);
- Auscultation: listen for bruits (AAA); both sides (renal)
then femoral; Buerger test: raise your legs 45 deg for
10-15 seconds (if there is pallor – suspect PVD) then I
would like you to sit down and hang your legs from the
edge of the bed (check for cyanosis or dusky red)
- What is the ABI?
Examination of Varicose Veins (Case 148R8)
Risk factors
- Female sex
- Family history
- Pregnancy
- Multiparity
- Age
- Occupation
- Diet (low fiber)
Examination
- Inspection:
o Distribution:
ƒ Below the femoral vein in the groin
to medial side of the thigh to lower
leg Æ saphenous vein
ƒ Back of leg to calf area Æ short
saphenous vein
o Signs of inflammation, cutaneous venous
flares, pigmentation, edema,
lipodermatosclerosis, dermatitis/eczema,
venous ulcers, loss of hair, atrophy of skin,
color change of the skin (deep blue, black,
purple), venous impulse at saphenofemoral
junction
- Palpation
o Hard: thrombosis; tender: thrombophlebitis
o Temperature
o cough impulse
ƒ Place fingers over line of vein
immediately below the fossa
ovalis (saphenofemoral
junction)Æ ask patient to cough
4 
Æ impulse or thrill will be felt
expanding and travelling down the
long saphenous vein
ƒ Marked dilated long saphenous
vein in fossa ovalis (saphena
varix) will confirm incompetence
Æ disappearas when patient lies
down
- Special tests: Trendelenburg test (checks the level of
incompetence) Æ long saphenous vein, short
saphenous vein and perforators
o Patient lies down and leg is elevated to 45
deg. To empty the veins
o Apply torniquet with sufficient pressure to
prevent reflux over the upper thigh
o Patient stands
o Long saphenous system will remain
collapsed if there are no incompetent veins
below the level of fossa ovalis. When
pressure is released, the vein will fill rapidly
if the valve at the saphenofemoral junction is
incompetent
o Doubly POSITIVE: is when veins fill rapidly
before the pressure is released and then
with a rush when released (coexisting
incompetent perforators and long
saphenous vein)
- Perthes Test
o Put tourniquet on mid-thigh Æ ask patient to
stand and up and down on the toes for 10x
after releasing some of the blood.
o Collapsed veins are normal
o If superficial veins increase in prominence or
pain Æ deep vein are occluded or
perforators are incompetent
o If veins are unusual in distribution Æ
exclude pelvic neoplasm/mass that is
obstructing the deep vein system
- Confirmatory: venous Doppler ultrasound
Management
- Refer for Doppler ultrasound for accurate diagnosis
- Use supportive stockings (apply in the morning before
standing out of the bed)
- Avoid scratching skin over the veins
- Sit with legs on a foot stool
- Maintain ideal weight
- Eat high fiber diet
- Treatment options
o Sclerotherapy (use a small volume of
sclerosing agent Æ particularly below the
knee)
o Surgical ligation and stripping Æ remove
obvious varicosities and strip perforators
Complications
- Superficial thrombophlebitis
- Skin eczema
- Skin ulceration
- Bleeding
- Calcification
- Marjolin ulcer (SCC)

EXAMINATION OF THE ABDOMEN
Recent hematemesis in a 50-year-old man (Chronic Liver
Disease)
Case (Condition 70): You are an intern in the ED and a 50-year-
old male having had hematemesis for about 500ml of fresh
blood 2 hours ago accompanied by transient feeling of
lightheadedness and sweating. The patient is alcoholic and
likely to have chronic liver disease on the basis of history that
you have taken.
Task
a. Perform relevant and focused PE of the patient
b. Explain actions and what you are looking for to
examiner
c. Describe findings as you proceed
d. No need to take further history
Physical examination
- Is my patient hemodynamically stable
- Consent
- Exposure: midchest to symphysis pubis
- Inspection:
o General appearance: Patient lying
comfortably. Abdomen moving with
respiration. He is not cachectic. There is no
obvious jaundice or pigmentation. He is well
oriented. IV drug marks
o Hands: clubbing, cyanosis, leukonychia,
pallor, CRT, palmar erythema, dupuytren
contractures
o Raise hands Æ flapping tremor/asterixis
(20-30 seconds)
o Arm: Spider nevi, bruising/petechia, scratch
marks, IV drug marks, tattooing or body
piercing
o Face: anemia and jaundice, Kayser-
Fleischer rings, parotid gland enlargement,
fetor hepaticus, flushing/congestion of the
face; Mouth: stomatitis, gingivitis,
ulcerations, telangiectasias
o Lymph nodes: cervical, axillary, inguinal
o Chest: spider nevi and gynecomastia
- Abdomen
o Inspection: distention, caput medusa, visible
pulsations, visible peristalsis, striae,
bruising, hernia orifices
o Inspect at level of tummy: ask patient to
breathe in and out through the mouth Æ
look for visible masses
o Palpation: Ask if patient has pain anywhere
in the stomach; Relax and breathe in and
out; mass or tenderness on superficial
palpation; deep palpation; palpate liver
o Liver span: from midclavicular line (Normal:
6-12)
o Spleen
o Percussion: shifting dullness for ascites
(percuss from right towards left side)
o Auscultation: bowel sounds and venous
hum (between umbilicus and xiphisternum)
o Testicular atrophy
o Scratch marks in legs and edema;
sensations
o DRE!!!!
5 
Perforated Peptic Ulcer
Case: You are an HMO in ED and a middle-aged man comes to
you because of acute abdominal pain. He had low back pain last
week and was prescribed NSAIDs. He is a smoker and an
alcoholic beverage drinker.
Task
a. Focused examination
b. Diagnosis and management
Case 2: John aged 45 years presents to ED of a local hospital
where you are working as HMO 1. He had severe abdominal
pain since this morning which is getting worse now. He had
vomited once but now had only dry retching. He took panadol
and neurofen but with no relief. He had not experienced such
pain in the past. He is a smoker and drinks moderate amount of
alcohol on weekends.
Task
a. History (started after breakfast, 10-11 in severity,
epigastric, takes panadol and neurofen for knee pain)
b. Physical examination (unwell, tired, BMI 24, PR:
120/min, mild dehydration, rebound, guarding and
rigidity)
c. Differential diagnosis and management
Examination
- Is my patient hemodynamically stable
- General appearance: lying on bed, unwell and in pain.
offer painkiller (morphine 2.5mg IV + metoclopramide)
- Vital signs (BP with postural drop)
- Inspection:
o Abdomen not moving with respiration
o General inspection of abdomen: scars,
distention, jaundice, pigmentation
- Palpation:
o Where do you feel the pain?
o Superficial palpation Æ tenderness
o Guarding, boardlike rigidity, rebound
tenderness on deep palpation
- Auscultation: Bowel sounds
- Hernia orifices
- DRE
Investigations
- FBE, ESR/CRP, blood group and crossmatching
- U&CE, LFTs, BSL,
- Amylase and lipase
- Erect CXR (free gas under diaphragm) and Xray of
abdomen (supine and upright)
Differential Diagnosis
- Perforated viscus
- Acute pancreatitis
- Mesenteric ischemia
- Acute cholecystitis
- AMI
- If female: Ectopic pregnancy, ovarian cyst
rupture/torsion; PID; miscarriage
Management
- Admit and call surgical registrar because it is an acute
abdomen most likely due to peptic ulcer
- Pass 2 IV line and start fluids for full resuscitation
- Pass NGT to decompress stomach
- NPO
- Insert indwelling catheter to monitor I&O
- Start IV antibiotics
- Surgery (Exploratory laparotomy)

Examination of an Inguinal Hernia
Case: You are a GP and your next patient is a 40-year-old
laborer. 2 weeks ago, he felt pain in his right groin after heavy
lifting at work and a week later, noticed a lump in the groin
which was not there before.
Task
a. Perform focused physical examination
b. Diagnosis and management
Differential Diangosis
- Hernia
- Lymph node
- Undescended testes
- Lipmoma
- Hydrocele
- Saphenovarix
- Aneurysm
- Neuroma
Examination
- Consent
- Do you have any pain in this area?
- On standing:
o Inspection: site of swelling (whether medial
or lateral to pubic tubercle), size, shape,
color of underlying skin, and contour, signs
of inflammation. scar marks
o Scrotum (extent of hernia; varicocele and
visible pulsation for saphenovarix)
o Ask patient to reduce swelling, look at other
side then cough
o Palpate the scrotum (can get above the
swelling: hydrocele, epididymal cyst, lipoma,
varicocele Æ testicular swellings)
- On lying:
o Check if swelling is reducible then check for
cough impulse; borders, temperature,
tenderness; palpate testes, epididymis and
spermatic cord
o Determine whether femoral or inguinal:
ƒ Femoral: if it lies 4 cm below and
4 cm lateral to pubic tubercle
ƒ Direct inguinal: above pubic
tubercle and inguinal ligament; 1
cm above pubic tubercle; lies
medial to the inferior epigastric
vessel; sac lies behind spermatic
cord
ƒ Indirect inguinal: above pubic
tubercle; lateral side of inferior
epigastric vessel; sac lies within
the spermatic cord so it can
descend to the testes
o Ring occlusion test
ƒ Occlude deep inguinal ring and
ask patient to cough Æ if it’s
coming out Æ direct inguinal
hernia Æ release pressure again
then hernia comes out Æ direct
inguinal hernia
ƒ Trace finger into spermatic cord
into superficial inguinal ring and
ask patient to cough Æ if sac hits
finger Æ indirect inguinal hernia
6 
o Three finger test
ƒ Put index, middle and ring fingers
in the 3 openings: one finger at
4cm above and below the pubic
tubercle, other finger at the DIR
and SIR Æ ask patient to cough
Æ where you feel the impulse
then diagnostic
o Palpate the LN, femoral pulse
- Describe hernia to examiner: femoral/inguinal,
reducible/irreducible, direct/indirect
Management
- Keep an ideal weight
- Adjust diet to avoid constipation
- Avoid activities that increase intra-abdominal pressure
(heavy lifting, straining and coughing)
- Avoid smoking
- Referral for surgical consultation. Done usually by
laparoscopic surgery
- Complications: infection, bleeding, anesthesia
complications, swelling, damage to nearby organs
(inferior epigastric vessels or inguinal nerves),
recurrence
MUSCULOSKELETAL EXAMINATION OF THE BACK
Examination of Low back
Case: A patient presented to your GP clinic complaining of back
pain.
Task
a. Perform physical examination of the low back
‐ Inspection: walk on heel, trendelenberg,
‐ Palpation: spinal and paraspinal, greater trochanter,
Red flags for back pain
‐ Incontinence
‐ Perianal area numbness
‐ Loss of rectal tone
Examination
‐ Inspection: Hairy patch on the back (spina bifida), café
au lait spots, stigmata of neurocutaneous disease,
muscle wasting or erythema, extended lordosis,
kyphosis, scoliosis, equal leg length, hip and shoulder
length level
‐ Assess gait (normal phases of walking without
limping, walking on heels, toes, squat (proximal bulk
of muscles)
‐ Palpation: with two thumb, palpate for spinal
tenderness, sacroiliac joints, iliac crest, greater
trochanter, ischial tuberosities, ASIS, PSIS
‐ ROM: flexion, extension, lateral flexion, lateral
rotation; Trendelenburg test
‐ Schoberg test: 10 cm above and 5 cm below the
dimple of venus and ask patient to touch toes Æ
should be >20cm
‐ Ask patient to sit at edge of the bed and test reflexes
(ankle and knee, clonus and babinski); hip flexion
against resistance, then sensory levels
‐ ROM of hip: hip flexion with knee extended - 90, and
with knee flexed 135, Internal and external rotation
(look at position of patella), flexion and extension of
knee, inversion/eversion and flexion/extension of foot,
dorsiflexion and plantar flexion of great toe, extension
of hip;
‐ Power of hip and knee against resistance

‐ Modified Straight leg-raising Test (L4-S1) Æ tests
root tension L3-4, L4-5, L5-S1 Æ passively lift the leg
while the patient is supine to maximum he can
tolerate, raise the leg to just below the level and
dorsiflex the foot
‐ Slump Test: patient at the edge of the bed and
slumping and bed head forward to maximum, lift up
head as if doing SLR test, release leg until pain
disappears, and put pressure by putting dorsiflexion,
release neck and dorsiflexion
Clinical Features
L2 Weakness of Iliopsoas muscle (Hip flexion)
Loss of sensation over the thigh and the lower
part of the groin
Reflex: None
L3 Weakness of quadriceps (Knee extension)
Loss of sensation over the patella
Reflex: Knee jerk
L4 Weakness of quadriceps and inversion at subtalar
(Ankle dorsiflexion and cannot walk on the
heel)
Reflex: Knee
L5 Extensor hallucis and digitorum longus (Great toe
dorsiflexion and long extensors and everters)
Reflex: None
S1 Flexor hallucis and digitorum longus and tendon
Achilles: weakness of Plantar flexion and foot
eversion (Toe walking)
Reflex: Ankle Jerk
‐ Do PR
MUSCULOSKELETAL EXAMINATION OF UPPER LIMBS
Examination of the Shoulder
Book Case:
- Consent
- Inspection: check for symmetry; check joints both
shoulders are equal; contour of muscles; no muscle
atrophy; bone, muscle, skin and joint; comment on
neck (neurocutaneous stigmata of associated disease,
bruise, deformities, erythema, neck contour is fine),
temperature is equal, musculoskeletral structures look
in place.
- Injury to circumflex nerve if there is shaving of deltoid
- Palpation: both clavicles, acromioclavicular joint,
bursa, bicipital tendon, suprasinous muscles, midline
and paraspinal areas and infraspinatus, examine
police patch (circumflex nerve), compare pulse,
- Check full ROM: flexion and extension of shoulder
joint, abduction to glenohumeral joint, scapula sliding
over thoracic cage, adduction to 0 and across the
body, internal and external rotation, touch tip of
scapula and scratch thumb between scapula
(combined adduction and internal rotation) then
combined abduction and external rotation, then
circumduction
- Stool: passive movement
- Test power of muscles: resists hands on biceps (full
flexion and extension); do chicken wings
(abduction/adduction); full external/internal rotation
- Pulses!
- Neurocutaneous structures: use pin and cotton
- Throw a ball: apprehension test: impending
dislocation/subluxation/joint unstable if positive
7 
Management of axillary nerve injury
‐ In many cases, spontaneous resolution happens
spontaneously and no treatment is needed. It may
take as long as one year.
‐ If there is any pain, we can give you medication such
as paracetamol in mild pain or if severe/stabbing pain,
other medications such as gabapentin or TCAs can
also be given.
‐ If not controlled refer to surgery and surgical options
include nerve grafting/reconstruction.
‐ Refer to physiotherapy to regain muscle strength and
function of nerve.
Examination of the Hand
- Joints, Pulse, Nerves, Muscles and Tendons!!!
- If with trauma: Pulse, nerve function, tendons, joint,
muscle
- If rheumatological examination: joint,
tendons/nerves, muscles, pulse
- Inspection: nails Æ psoriatic nails (pitting,
onycholysis, hyperkeratosis), subluxation, muscles,
shiny, tighetened skin, thickening of tendons,
erythema, clubbing, deformity of small joints of the
hand (phalanges, MCP or wrist joint), nodules on the
level of elbow swelling, signs of inflammation,
deformity, no muscle wasting or thickening of
hypothenar or thenar muscles, pallor, dupuytren
contracture
o Radial deviation of wrist
o Z deformity thumb – flexion of MCP and
extension of PIP (RA)
o Boutonierre deformity – flexion of PIP,
extension of DIP (RA)
o Swan neck deformity – flexion of DIP and
extension of PIP (RA)
o Heberden – DIP (OA)
o Bouchard nodes – PIP (OA)
o Sausage-shaped fingers – telescoping of
fingers (psoriasis and scleroderma)
- Palpation: temperature; elbow, radius, ulna, lower end
of the ulnar styloid processes with 2nd finger,
(denotes RA Æ especially radial styloid and
associated with de Quervain tenosynovitis, severe
OA), wrist and bones of the hand (with thumb), press
from the side and up to detect for any effusion,
crepitation, dupuyren contracture, wasting of
thenar/hypothenar muscles, radial pulse, CRT,
sensation
- ROM (Active then passive); open and close hand to
check for crepitus/tenosynovitis
o Elbow: flexion and extension
o Wrist: flexion, extension, lateral and medial
deviation, supination and pronation; degree
of flexion and extension
o Thumb: flexion, extension, adduction,
abduction, opposition
o Hand: abduction and adduction
- Power
- Nerve Tests:
o Pin touch test: median nerve
o Crush finger with thumb: ulnar nerve
o Full extension of wrist: radial nerve
o Fromen’s test
- Vibration and Proprioception: may avoid
- Carpal tunnel
o Phalen test
o Tinnel
o Finkelstein
 8 
 
- Functions of the hand - Palpation: hip lying on the same level by palpating
o Grip strength with thumb the ASIS, greater trochanter (tenderness if
o Key hole test there is subtrochanteric bursitis), femoral pulse
o Comb hair midpoint between ASIS and pubic tubercle), palpate
o Write name lateral to femoral pulse to check for tenderness on
o Undo buttons femoral head (osteoarthritis), muscles on the inner
side of the hip and front (adductor tendinitis)
Other features of RA - Measure leg length: Apparent and true leg length
- Skin: rheumatoid nodules (measuring tape)Æ discrepancy in true leg length
- Head: scleritis in eyes signifies pathology of hip joint; if in apparent leg length
- Lungs: nodules, fibrosis, Caplan syndrome means tilting of pelvis
(pneumoconiosis) - Active and Passive Movements then Power:
- Heart: pericarditis o Hip flexion: raise leg to chest
- Abdomen: splenomegaly o Extension: can ask patient to lower the leg
- Hematologic: neutropenia (felty syndrome = RA + down or at the back ask patient to raise the
neutropenia + splenomegaly), anemia leg while knee is flexed; palpate the dimple
of venus or press hip (sacroiliac joint
Osteoarthritis tenderness Æ sacroilitis)
- Usually carpometacarpophalangeal and DIP o Abduction and Adduction (support hip)
o Internal and external rotation (flex and
MUSCULOSKELETAL EXAMINATION OF THE LOWER support the knee)
EXTREMITY - Thomas Test: flexion deformity of the hip; keep hand
under spine and flex both hips and knees and ask the
patient to lower one leg; if not done properly, flexion
Examination of the Hip (Trochanteric Bursitis) deformity will be disguised by lumbar lordosis
compensatory movement
Case: A 45-year-old female complained of pain in the right outer - Squeeze Test: flex knee at 90 degrees ask patient to
hip that travels down to her legs since last week. squeeze thighs in hand Æ (+) in adductor
tendinitis/osteitis pubis
Task - Tests for Sciatica
a. Examine the patient o Modified Straight Leg Test (L4-S1)
b. Diagnosis and management o Tibial Nerve Stretch Test (L4-S3)
o Femoral nerve Stretch Test (L2-4)
Features:
- Inflammation of bursitis or tendinopathy of the gluteus Diagnosis and Management
medius tendon - Most likely you have a condition called trochanteric
- Common in patients on sports or gardening, increased bursitis. The bony prominence of the thigh bone in the
weight/BMI upper part is the greater trochanter. There is a
- Pain around lateral aspect of hip traveling down the protective shock absorber over the bone called
leg “bursa”. The muscles of the buttock is also attached to
- Trendelenburg test may be positive this bone by the tendons. If there is inflammation of
- Female >45-50 the tendon or bursa, it is called trochanteric bursitis or
- Tenderness of the greater trochanter and/or pain tendinitis.
on abduction - You need to rest and reduce the activity for about a
- Treatment: NSAIDS, RICE, strengthening exercises, few days. Put an ice pack on the painful side and I will
injection therapy give you some painkillers to relieve the pain or
analgesic creams for massage. Please avoid sleeping
Differential Diagnosis on the affected side. You can use sheep skin mat or a
- Avascular necrosis of femoral head small pillow to elevate the involved area
- Osteoarthritis of the hip - I will refer you to a physiotherapist for strengthening
- Lumbar spine radiculopathy exercises.
- Iliopsoas tendinitis (flexors of the hip) Æ pain on - If severe pain: local anesthetic + corticosteroids;
stretching of the hip flexor or resisted hip flexion surgery (rarely)
- Investigations: XRay Æ rule out osteoarthritis; USD:
Examination can demonstrate the pathology
- Expose from waist down - Overweight: lifestyle modification
- Assess gait (limping), walk on heels (L5) then toes
(S1); squat and stand; Gait and Hip Examination (Osteoarthritis of the Hip)
- Trendelenberg test (checks abductors of the hip Æ
gluteus medius): Æ leg which the patient is standing Case: A 64-year-old man with a history of pain on his right hip
is the one being tested Æ SOUND/NORMAL side is joint for the last 6 months comes to your GP clinic. The pain is
going to SAG worse with activity. He tried panadol but didn’t get relief from the
- pain.
o Tests gluteus medius muscles
o Problem in hip joint (severe OA) Task
o Shortening of neck of femur due to fracture a. Relevant hip examination and give commentary
o SCFE (kids) (limping, unable to walk heels and toes and squat,
- Inspection: both hips straight, swelling, deformity, trendelenburg unable to do on the right side because
signs of inflammation, wasting of the muscles, flexion of the pain, leg length is normal, tenderness over the
deformity (side), back (spine is centered, wasting,
deformity)

right femoral head, flexion deformity on right side,
limited in range of movements on the right side,
thomas test positive)
b. Diagnosis and management
Case 2: You are working in a hospital followup outpatient clinic.
This 35-year-old man sustained a posterior dislocation of the
right hip in a MVA years ago. There were no associated
injuries, the dislocation was reduced and he had a period of bed
rest within traction followed by graduated ambulation and weight
bearing. He has been well since and has no problems apart
from occasional aching on prolonged exercise. He presents to
you for a checkup for insurance purposes.
Task:
a. Perform PE of the hip with commentary
b. Advise patient of your opinion about the condition of
his hip
c. Advise patient of any further test which are required
Features
‐ Most common form of hip disorder
‐ Intrinsic disorder of articular cartilage or to secondary
OA
‐ Risk factors: previous trauma, DDH, septic arthritis,
acetabular dysplasia, SCFE, past inflammatory
arthritis
‐ M=F, usually bilateral; insidious; worse with activity,
relieved by rest and then nocturnal and after resting;
stiffness, limp and deformity; referred pain to groin,
medial aspect of thigh, buttock or knee
‐ PE: antalgic gait, gluteal and quadriceps wasting, first
hip movements lost: IR and extension, fixed flexion
deformity, hip held in flexion and ER (atfirst) Æ IR,
extension, abduction, adduction, flexion, ER
‐ Treatment:
o Weight loss
o Relative rest
o Crutches for acute pain
o Analgesia
o Walking stick
o Physiotherapy
o Physical therapy (isometric exercise)
o Surgery: with severe pain or disability
unresponsive to conservative measures;
total hip replacement (old); femoral
osteotomy (younger patients); hip
resurfacing (<60 years; >90% achieve good
results; last 15-20 years)
Differential Diagnosis
‐ Osteoarthritis
‐ Avascular necrosis
9 
Diagnosis and management
‐ It is a condition called osteoarthritis of the hip. It is a
condition resulting from wear and tear as a result of
excessive use of your joints over the years and also
due to old injuries in the affected joint. The cartilage
the covers and protect s the ends of the bones
gradually wears away causing the joint to become
rough and stiff. Most cases are mild and with
treatment, you can cope with it.
‐ Investigation: I will do an Xray of the hip joint to check
for bony spurs and narrowing of joint spaces.
‐ Management:
o Relative rest during acute pain, analgesia
and crutches
o Weight loss
o Heat: hot water bottle, warm shower, electric
blanket to reduce stiffness and pain
o Refer to physiotherapy for strengthening of
muscles and
o Occupational therapist for walking aids
o Surgery: hip joint is replaced by metal or
plastic and is successful in >90%
Adductor Tendinitis
Case: Your next patient in GP practice is a 20-year-old man
complaining of pain in the right groin.
Task
a. History for 2 minutes (playing football when suddenly
twisted and heard popping sensation; upper groin pain
radiating to the thigh)
b. Perform Physical examination
c. Diagnosis and management
Case: David aged 27 years presents to your surgery in a busy
afternoon. He tells you he is having pain in his right leg and
finds it hard to play Footy nowadays. He is a professional player
and represents his team at state level. He had no injury or
trauma and denies any fall also. He had got some treatment by
team Physio and had used Panadol and Neurofen with no relief.
David is otherwise well and works as a salesman in a well-
reputed firm
Task
a. Further history (right leg 2-3 weeks especially in the
right upper medial thigh or groin area)
b. Physical examination (resisted adduction increases
pain, + Squeeze test,
c. Probable diagnosis and management advise
Differential Diagnosis
‐ Adductor tendinitis
‐ Iliopsoas problems
‐ Stress fracture of femoral neck
‐ Osteitis pubis (chronic pain)Æ inflammation of
periosteal bone of symphysis pubis; pain on lower
tummy/pubic bone; point tenderness in symphisis
pubis;
‐ Hernia (Sport inguinal-femoral)
‐ Referred pain from lumbosacral spine
‐ Osteoarthritis of the hip joint
‐ Urologic disorders
Features
‐ Acute groin pain with history of twisting injury and
popping/snapping
‐ Pain Æ inner thigh

‐ Tenderness on palpation of the inner muscles of the
thigh and pain on adduction; squeeze test (+)
‐ RICE
‐ Prevention: stretching;
History
‐ Can you tell me more about what happened?
SORTSARA? Were you able to walk after that? Is it
for the first time? Did you have any numbness, tingling
or weakness? Swelling? Bruising? Did you take any
medications? Previous medications? General health?
History of joint problems?
Diagnosis and management
‐ Most likely you have a condition called Groin strain or
adductor tendinitis. It happens because of too much
stress on the muscles of your groin/thigh called
adductor muscles. If these muscles are tensed too
forcefully or suddenly they can tear causing pain. It is
a common condition during sports activity.
‐ Avoid activity until pain gets settled. Apply for 20-30
minutes for 3-4 hours until pain-free. You can also
compress the thigh with the help of elastic bandage or
tape.
‐ I will give painkillers and refer you to physiotherapy. If
still not relieved, I can refer you for corticosteroid
injection.
‐ Please come back if the pain is persistent. If we might
do ultrasound and Xray.
‐ Prevention: Do warm and stretching before doing
physical activity.
Examination of the Knee
Case (book pg229/280): A patient in your GP setting has past
history of twisting his right knee 6 months ago when foot got
caught on a broken pavement. He fell on the knee and it
became swollen and painful on the inner side. The swelling
caused a painful limp for several days and then subsided with
easing of symptoms.
Since then he has had intermittent attacks of pain on the inner
side of the knee with swelling, which settles within 24 hours, and
has had difficulty in straightening the leg fully. He is, on
occasion, apprehensive when twisting to the right. Between
attacks of pain he can walk normally with only a minor feeling of
pain on the inner side of the knee. He is otherwise well. This is
the first time he has consulted a doctor about this problem.
10 
Task
a. Focused examination of the knee
b. Differential diagnostic plan
Inspection:
Landmarks
- Patella
- Tibial tuberosity
- Popliteal fossa
- Quadriceps femoris
- Suprapatellar pouch
- Medial and lateral pouches Æ Peripatellar pouches
(obliterates when there is effusion)
- Anserine bursa
- Fractures, muscle wasting, scars (longitudinal Æ
TKR, keyhole) , effusion, erythema, neurocutaneous
stigmata
- Anterior plane: varus or valgus deformity
- Lateral: hyperextension or flexion abnormalities
- Posterior: swelling or baker cyst
- Observe gait: normal gait, limping, fixed flexion
deformity
- Squat and stand up (power and ROM Æ full flexion
and extension)
Palpation
- Temperature (of knee is 1 degree lesser than body),
Pulses (while seated – popliteal, dorsalis pedis,
posterior tibial), sensation (pain and light touch),
reflexes,
- Passive movement
- Knees flexed: palate quadriceps, suprapatellar
pouches, patella, patellar tendon, shin of tibia, lateral
malleolus and fibula, head of the fibula, and joint line,
iliotibial band, knee hip joint, adductor muscle,
gastrocnemius, Achilles tendon
- Patellar tap test and bulge test (mild effusion Æ
effusion
- Valgus and Varus stress test (+ if more than 10
degrees)
- Anterior and posterior drawser (+ if more than 10
degrees)
- Menisci
o Apley’s Grinding test
o External rotation, valgus and flexion or
internal rotation, varus and extension
- Patellar apprehension test (impending subluxation or
dislocation of patella)
Examination of ankle joint
- Inspection: try to walk first; change in color of skin,
bruises, deformity
- Palpation:
o Lateral: lateral malleolus, posterior tip of
lateral malleolus and 6 cm above, anterior
talofibular ligament, calcaneofibular
ligament, posterior talofibular ligament,
peroneal tendons, base of 5th metatarsal,
(sinus tarsi, distal syndesmotic ligament,
anterior calcaneal process Æ not
necessary)
o Media: medial malleolus, medial joint line
with 6 cm above, 3 strips of ligament,
navicular, anterior joint line, Achilles tendon,
heel, pulse, CRT
- ROM: plantar flexion, dorsiflexion, inversion, eversion,
neurovascular sensation, reflexes, power
- Tests for ankle instability: anterior drawer, talar tilt,
and squeeze tests (signals high ankle/syndesmotic
injury Æ patient needs MRI and referral for ORIF
 11 
 
Lower Leg Examination of a Patient with Diabetes Mellitus Treating cuts and injuries
(Diabetic Foot) - Clean would with mild antiseptic (liquid savlon or dilute
betadine)
Case: Your next patient is a 55-year-old female with long- - Cover with clean gauze
standing diabetes. - See GP if does not heal within 2 days or there are
signs of infection
Task - Refer to podiatrist, dietitian, diabetic educator,
a. Perform physical examination of the lower limbs. ophthalmologist and nephrologist

- Ask patient to walk looking for gait and normal phases

of gait Æ high-stepping gait (indicates loss of
proprioception or joint position sense)
- Inspection:
o Needle marks and fat hypertrophy/atrophy,
wasting (especially quadriceps); charcot
joints (deformed knee joints)
o Skin: loss of hair, atrophy of the skin,
redness, cyanosis, signs of inflammation,
edema
o Feet for obvious deformities, boils, corns
and calluses, hammer toes (proximal
phalanx is flexed); mallet toe (DIP is flexed);
toe clawing (flexion of both DIP and PIP),
hallux valgus, bunions, tinea
o Nails (thickening, ingrown toe nail, change
of color, cyanosis), toes (cracks, ulcers)
- Palpation:
o CRT, temperature, edema, pulses
o Neurologic examination: sensation, vibration
(toe Æ medial/letaral malleolus Æknee Æ
ASIS) proprioception, power (ankle and not
knee), tone, reflexes (ankle, knee Æ may
be decreased or absent)
- Urine dipstick, BSL, funduscopy

Diabetic Foot care

- Keep diabetes under good control and do not smoke
- Check feet daily (sores, infection or unusual signs)
- Wash feet daily with lukewarm water, dry thoroughly
especially toes and soften dry skin especially around
the heels; applying methylated spirits between toes to
help stop dampness
- Attend to toenails regularly (clip straight across with
clippers, do not cut them deep into corners or too
short across, file any rough edge)
- Wear clean cotton or wool socks daily
- Exercise your feet each day to help circulation
- Check insides of shoes to make sure no nails are
pointing into the soles
- Annual foot examination in doctor’s office

How to avoid injury

- Wear good-fitting, comfortable leather shoes
- Shoes should never be broken-in (should fit from the
start)
- Shoes must not be too tight or too loose
- Do not walk barefoot especially outdoors
- Do not cut your own toenails if with poor eye sight
- Avoid home treatments and corn pads that contain
acid
- Be careful when walking around the garden and home
- Do not use hot-water bottles or heating pads on your
feet
- Do not test temperature of water with your feet
- Take extra care when sitting in front of an open fire or
heater