CLINICAL EXAMINATION OF THE RESPIRATORY SYSTEM Face, mouth@ and eyes Pursed lips? Central cyanosis? ‘Anaemia? Homer's syndrome Jugular venous @ pulse Elevated? Pulsatile? Blood pressur Arterial paradox? Radial pulse| Rate Rhythm Hands| Digital clubbing Tar staining Peripheral cyanosis ‘Signs of occupation CO, retention flap Finger clubbing Observation Inspection| Deformity (e.g. pectus excavatum) Scars Intercostal indrawing ‘Symmetry of expansion Hyperinflation Paradoxical rib movement (low flat diaphragm) Idiopathic kyphoscoliosis Palpation From the front: Trachea central Cricosternal distance Cardiac apex displaced? Expansion From behind: Cervical lymphadenopathy Expansion Percussion Resonant? Dull? ‘Stony dull’ (effusion)? normal, bronchial, louder or softer? ‘Added sounds’ wheezes, crackles, rubs Spoken voice (vocal resonance): absent (effusion), increased (consolidation)? Whispered voice: whispering pectoriloquy 2 Cor pulmonale 7 Venous thrombosis + Respiratory rate * Cachexia, fever, rash? * Sputum + Fetor + Locale ‘Oxygen delivery (mask, cannulae) Nebulisers InhalersCLINICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM G Face, mouth and eyes Pallor Central cyanosis Malar flush Dental caries Funai (retinopathy) ‘Stigmata of hyperlipidaemia Poor oral hygiene in and thyroid disease y Familial hyperlipidaemia infective endocarditis Precordium Jugular venous pulse Inspect Palpate— ‘Foight apex, thls, Rand L Waveform Ventricular heaves Auscultation Bal for low-pitched heart sounds and mid-diastolic murmurs Back Lung crepitations Sacral osdema Abdomen Hepatomegaly Carotid pulses! Volume Ascites: x Aortic aneurysm Character oe Jugular venous pulse Tendon xanthomas (hyperlipidaemia) Clubbing Splinter haemorrhages and other stigmata of Femoral pulses infective endocarditis Radio-femoral delay Bruits Legs Peripheral pulses Oedema a Splinter haemorthage Symptoms and wellbeing * Breathlessness ‘bistess ote Body habitus b PSoty mass fobosity, cachexia) a. ‘ Martan's and other syndromes Vasculitis in Peripheral Tissue perfusion infective edema in CCyanosis and clubbing Sen tempera ondovardlis congostve imeomplex cyanotic + Sweating cardiac fallure congenital heart disease 1 One expatCLINICAL EXAMINATION IN ENDOCRINE DISEASE Eyes Facial features, Graves" disease Hypothyroid Blood pressure| Biplopia HiBatiom Hypertension in Visual field defect Acromegaly Cushing's and Conn Hair Coshing’s phaeochromocytoma ‘Alopecia Mental state Hypotension in adrenal Frontal balding “Sthargy oomrsern insufficiency Depression " y Demmansic in acromegaly Pulse tide Neck Arial fbrilation Voice sinus tachycardia Moarse, 0.9. hypothyroid Bradyeardia ities ‘Skin ore 2" Hair distribution, Nodules Dry/greasy Pigmentation/pallor Bruising Vitiligo Striae Multinodular goitre Breasts Vitiligo in organ-specific [ Galactorrhoea ‘autoimmune disease Gynaecomastia | Body fat Hands Central obesit Palmar erythema Cushing's an« ‘Tremor yrowth hormone Acromegaly jeficiency Carpal tunnel syndrome Fragility fractures (e.g. of vertebrae, neck of femur or distal radius) Pubertal development Pigmentation of creases Testicular volume due to high AGTH levels in Addison's disease Proximal myopathy Myxoedoma Acromegalic hands. Note soft issue enlargement causing “gpade-like’ changes Observation ‘= Most examination in endocrinology Helott and.welant is by observation. « Astute observation ease can often yield ‘spot’ diagnosis, meena, + Emphasis varios depending on inGravow Glandinormone rveed GiseaseCLINICAL EXAMINATION OF THE GASTROINTESTINAL TRACT Head and neck @ Pallor Jaundice GH 5 ‘Angular stomatitis, examination Glossitis, Parotid enlargement Mouth ulcers Dentition Distension Lymphadenopathy Rospiratory Scars Colour > Virchow’s gland bras Tender/guarding Masses Viscera Liver (Ch. 13) Kidneys (Ch. 7) Spleen Percuss, Ascites Viscera ‘Auscuttate Bowel sounds Bruits Atrophic glossitis, Angular stomatitis Koilonychia Signs of liver disease (Ch. 13) Hernias Lymph nodes Perineum/rectal Fistulae Skin tags ‘Clubbing Haemorthoids Masses Skin and nutritional @ ‘status Muscle bulk Signs of weight loss * Distressed/in pain? + Fever? + Dehydrated? + Habitus gangrenosum * Sid: Haemorrhoids.CLINICAL EXAMINATION OF THE ABDOMEN FOR LIVER AND BILIARY DISEASE inspection Scars Distension Movement Veins Testicular atroph Gynaecomastia ee: = ‘Spider naevi f Abdominal swelling " in ascites Face| Jaundice Spider naovi Parotid swelling hhinophyma s Dilated abdominal wall veins (caput medusae) Xanthelasma and Abdomen: palpation Jaundiced Hepatomegaly sclora in a patient Splenomegay with chronic cholestasis Hands| ‘Clubbing Abdomen: Dupuytren's contracture ae : Ascites Smooth nails (from scratching) Bruising Flapping tromor (when arms outstretched Abdomen: ‘and hands dorsifiexed) ‘auscultation Bowel sounds Hepatic bruit + Unkempt + Smell of alcohol or fetor hepaticus i Race Palmar erythema + EncephalopathyEXAMINATION IN BLOOD DISORDERS Fundi Haemorthage Hyperviscosity Engorged veins Papilloedema Haemorrhage Conjunctiva Pallor Jaundice Fundal haemorrhage Neck, axilla Lymph nodes Mouth Lips: angular stomatitis, telangiectasia Gum hypertrophy Tongue: colour, smoothness Buccal mucosa: petechiae Tonsils: size Abdomen Masses Ascites Hepatomegaly Splenomegaly Inguinal and femoral nodes Gum hypertrophy Pulse Rate Joints Deformity ‘Swelling Restricted movement Hands Perfusion Telangiectasia ‘Skin crease pallor Koilonychia Feet Peripheral circulation Toes: gangrene ® urinatysis Blood Urobilinogen Observation Kollonychia + General well-bein. * Colour: pallor, plethora + Bleeding, e.g! purpura and bruising + BreathlessnessCLINICAL EXAMINATION OF THE MUSCULOSKELETAL SYSTEM Muscle-wasting le, Guarded, held in Global wasting loose-pack position from for capsule glenohumeral (adduction, arthritis, internal rotation for shoulder) ‘Swelling — characteristic of joint problem Deformity Joint: e.g. synovitis of Index and middle proximal interphalangeal joints Periarticular: e.g. olecranon bursitis Skin changes Bone: 6.9 Paget's disease of tibia Inspection during movement Restriction Increased range Pain on usage ‘septic arthritis Palpation with ‘of the ankle movement Scars Tenderness Psoriasis Increased warmth Vasculitic rash Swelling Detailed regional Sapte ‘examination Resisted active involves ‘look’, inovernent ‘feel’ and ‘move’ Stress testsCLINICAL EXAMINATION OF THE NERVOUS SYSTEM \Cranial nerves Higher cerebral function = Orientation Memory Speech and language Localised cortical functions Right 12th nerve palsy: ‘wasting of right side of tongue Neck and skull ‘Skull size and shape Neck stiffness and Kerig’s test Motor Carotid bruit ‘Wasting, fasciculation Abnormal posture Abnormal movements ‘Tone (including clonus) ‘Strength Coordination Back’ Tendon reflexes. Scoliosis Abdominal reflexes Operative scars, Plantar reflexes Evidence of spina bifida occulta Winging of scapula ‘Wasting of right thenar ‘eminence due to cervical rib Winging of right scapula (muscular dystrophy) Sensory Pin-prick, temperature Joint position, vibration ‘Two-point discrimination Stance Posture Rombord's test cai ‘Arm swing Pattern Tandem (hee!-toe) Observation | General appearance - Mood (e.g. anxious, depressed) + Facial expression (or lack there!) |- Handedness }- Nutritional status | Blood pressureJoint involvement 2.9. Psoriatic arthritis Distribution of rash (Examine the fully indressed patient in bright, unitorm light) ‘Symmetrical, 2.9. psoriasis Asymmetrical, 8.9. granuloma annulare Proximal, 6.9. acne Distal, 0.9. log ulcerCLINICAL EXAMINATION OF THE PATIENT WITH DIABETES Eyes Visual acuity Cataractiens opacity Fundoseopy Insulin injection sites Bruising Lumps (lipodystrophy) ‘Subcutaneous fat deposition (ipohypertrophy) ‘Subcutanoous fat los Head Xanthelasma Cranial nerve palsy/ ‘eye movements/ ptosis Neck (lipoatrophy) Carotid pulses: Erythema, infection Bruits Thyroid enlargement ‘Abdomen Hepatomegaly Axilla Legs ‘Muscle-wasting Sensory abnormality Granuloma annulare Hair loss Tendon reflexes Acanthosis nigricans Blood pressure. skin @ Pigmentation Neerobiosis lipoidica Granuloma annulare Vitiligo Necrobiosis lipoidica, Feet Inspection (callus, ulcers, Charcot neuropathy, fungal infection) Circulation (peripheral Hands pulses, temperature) Dupuytren’s Neurology (light touch, egentracture vibration, pin prick od ee rote Tage ngerum + Weight loss in insulin deficiency imited joint mobil * Obesity in type 2 diabetes Wasting ona + Mucosal candidiasis * Dehydration—dry mouth, J tissue turgor * Air hunger- Kussmaul breathing in ketoacidosis Sensory abnormality leuropathic foot ulcerCLINICAL EXAMINATION OF THE KIDNEY AND URINARY TRACT Lungs Crepitations in Fundoscopy @ fiuid overload Heart Extra heart sounds in fiuid overload Pericardial friction rub* Enlarged kidneys Local tendemess Renal or other arterial bruits in renal vascular disease Hypertensive changes Male genitalia Rectal examination— prostate Jugular venous pressure Elevated in fluid overload (DD Ante oedema Blood pressure Often elevated (D) Peripheral neuropathy* Urinalysis for blood Ban and protein Yellow complexion’ Bruising* Excoriation of pruritus" Reduced skin turgor in fluid depletion Urine microscopy ** Tiredness “Brown line! + Respiratory rate and depth igmentaiion, increased in metabolic acidosis of nails * Palo * Features of advanced chronic kidney disease (see also Fig. 7.4) PhimosisCLINICAL EXAMINATION OF THE PYREXIAL PATIENT Upper airway/ears Nasal obstruction/bleeding ‘Sinus pain Retropharyngeal abscess Granulomatous disease Otitis mediavexterma ‘Scalp ‘Temporal artery tenderness Metastases Neck stiffness Optic fundi ens spots Heomortage Convialfaxiary aude Smmphadonopathy Signe of immunocomprermisa estomegsiov Cheet/meart “Sone of tuberculosis Sipre of consolidations (choroidoretinitis) 2 rub or pleural effusion Soop Pevtcaraal rus Changing murmurs eyes Suggesting encocarcis Sachyearcla of Faeyr actvcun Jaume reoponce Mouth and oropharynx Denial sepsis ‘Signs of HIV/ immunocompromise e.g. Candida Tonsillar exudate Chest X-ray consolidation a 2 ae = eee = oe I etre Finger clubbing lymphadenopathy sues ope ee ‘Active rheumatoid Joints (any) ae sae Rash and skin nodules Erythema Hoat (aeamvyake) ‘Tenderness Effusion b Genitalia Ulceration Discharge Erythema nodosum Rectal examination Perianal cisease Prostatis, S ~ Tumour Meningococcal rash Bihar pes recauinINICAL EXAMINATION OF THE POISONED PATIENT Pupil size ‘Small: opioids, clonidine Large: tricyclic antidepressants, alcohol, amphetamines, cocaine, antihistamines Respiratory rate Reduced: opioids, benzodiazepines Incteased: salicylates Blood pressure Hypotension: tricyclic antidepressants, haloperidol Hypertension: cocaine, o-adrenocaptor agonists Right upper quadrant Trenal angle tenderness e.g. Paracetamol hepatotoxicity and renal toxicity Epigastric tenderness 2.9. NSAIDs, salicylates Rhabdomyolysis e.g. Amphetamines, caffeine Cerebellar signs e.g. Anticonvulsants, alcohol Extrapyramidal signs e.g. Phenothiazines, haloperidol, metoclopramide Cyanosis Any CNS depressant drug or agent causing methaemoglobinaemia, e.g. dapsone, amy! nitrite Heart rate Tachycardia or tachyarrhythmias: tricyclic antidepressants, ‘theophylline, antihistamines bradyarrhythmias: digoxin, B-blockers, calcium channel blockers, opioids Needle tracks Drugs of misuse: opioids ete. Body temperature Hyperthermia and sweating: ecstasy, serotonin re-uptake inhibitors, salicylates Hypothermia: any CNS depressant, €g. opioids, chlorpromazineCLINICAL EXAMINATION OF THE CRITICALLY ILL PATIENT Initial assessment Immediate management Airway: Support, ? Intubate Breathing: ‘Oxygen Continuous positive airway Raie pressure (CPAP), Chest movement on-invasive mo ventilation (NIV) Avscultation Intubate and ventilate Circulation: [Glircutation Venous access Pulse Fluids Rate Vasoactive drugs Rhythm Monitoring Nolime Heart to; ECG Blood pressure Respiratory rate; Sp O2 Peripheral perfusion: Bp aerate Torperatue GCS: pupil size, reaction Colour Urine output Capillary refill Central venous pressure [Disability Conscious love Qnitiat investigations Glasgow Coma Scale Full blood count Pupil responses Urea and electrolytes Localising signs Creatinine Glucose ‘Arterial blood gas lactate Coagulation Cultures: blood, urine, sputum Chest X-ray Recognising the critically ill patient ECG Cardiovascular signs Respiratory signs Neurological signs * Cardiac arrest + Threatened or obstructed —_—* Threatened or *Pulse rate <40 or > 140 bpm airway obstructed airway * Systolic blood pressure + Stridor, intercostal recession + Absent gag or (BP) < 100 mmHg + Respiratory arrest cough reflex + Tissue hypoxia + Respiratory rate < 8 or + Failure to maintain Poor peripheral perfusion > 35/min normal PaO and PaCO2 Metabolic acidosis + Respiratory ‘distress’: + Failure to obey commands Hyperlactataemia use of accessory muscles; * Glasgow Coma Scale * Poor response to volume unable to speak in (GCS) < 10 resuscitation complete sentences + Sudden fallin level * Oliguria: < 0.5 ml/kg/hr * Sp Op < 90% on of consciousness (check urea, creatinine, Kt high-flow O2 (GCS fall > 2 points) Rising PaCO2 > 8 kPa + Repeated or (> 60 mmHg), prolonged seizures or > 2 kPa (> 15 mmHg) above ‘normal’ with acidosisCOMPREHENSIVE GERIATRIC ASSESSMENT Cognitive function Abbreviated mental test Vision Muscle Wasting? Strength? Hearing Erect and supine blood pressure Postural hypotension? Wasting of small muscles of hands in theumatoid arthritis Pulse Per rectum Atrial fibrillation? Faecal impaction? Prostate size/ consistency in men Nutrition Joints. Body mass index Deformity? Height calculated Pain? from arm demispan Swelling? ‘or knee height 10 ‘compensate for loss of vertebral height ‘Severe kyphosis @ cattana oatance sas Measurement of ne ct to the above Abbreviated mental test Each correct answer soores 1 mark 1 What time is it? (10 the nearest hour) 2 What year is it 3 What is the name of this place/hospital? ‘4 How old are you? (exact year) 5 What is your date of birth Please memorise the following address: 42 West Street ‘6 When did the First World War begin? 7 Who is the present monarch 8 Please count backwards from 20 down to 1 '9 Can you recognise two people (e.g. relative or photograph) 10 Can you tell me the address | asked you to memorise a few minutes ago? Mini Mental State Examination used for more deatiled assessmant