Check List Samples

For sixth year medical students

General examination
GETTING READY Mark
1. Greeted the patient respectfully and with kindness.
2. Explained the procedure to the patient.
3. Stood by the right side of the patient
4. wash your hands
Mental Status Examination (MSE)
Assure that the patient can pay attention
A. Appearance
B. Level of Alertness:
C. Orientation:
D. Memory:
 Short-term:
 Long-term:
E. Mood: happy, depressed or angry
Complexions
I - Pallor:
1. In Lips and Hands
II - Jaundice:
1. In lower fornix of the eye
2. In the soft palate.
III - Cyanosis:
1. Central: examined in the tongue
2. Peripheral: examined in the tip of the nose, lobule of ear and tip of fingers.
Radial Pulse
1- Prepare equipment:
2- Explain the procedure to the patient.
3- Assist the patient to pronate and slightly fix the forearm.
4- Locate the radial artery just medial to the distal radius and proximal to the
patient's wrist on the thumb side.
5- Place the tips of the index, middle & ring fingers just proximal to the patient's
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 wrist on the thumb side, orienting them over the vessel.
6- Comment on
a. Rate:
b. Rhythm:
c. Volume:
e. special character:
f. condition of the vessel wall:
g. equality of both radial pulse (volume).

Examination of palpable arterial pulsations

Femoral artery:
Popliteal artery:
Posterior tibial artery:
Dorsalis pedis artery:
Brachial artery:
Superficial temporal artery
Common carotid artery
THE BLOOD PRESSURE
1- Remove the clothes
2- Place the cuff around the upper arm in a proper way
3- Wrap the cuff in a proper way
4- Arm relaxed and supported at the heart level
5- Close the valve
6- Palpatory method
7- Auscultatory method
8- Repeat while Standing
9- Comment
Axillary Temperature
1- Hold the thermometer opposite to the bulb.
2- Remove the disinfectant from the thermometer by rinsing with cold water.
3- Dry the thermometer.
4- Shake the mercury down to 35ºC using a snapping wrist motion
5- Ask the patient to lie in a supine or semi-Fowler position.
6- Place the bulb of the thermometer in the client's clean, dry axilla.
7- Hold the arm of the patient firmly to the side with the elbow flexed and the
hand in contact with the chest.
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 8- Wait three to five minutes before removing the thermometer.
9- Read the thermometer
10- Return thermometer to disinfectant solution
11- Wash the hands
12- Record the findings and explain to the patient.
13- Comment
RESPIRATORY RATE.
1 - Prepare the equipment: Watch or clock with a counter for seconds.
2- Assist the patient to a comfortable semi-sitting position
3 - Do not explain the procedure to the patient, pretend you are measuring the
radial pulse, while inspecting and counting the elevations of the chest wall in for 1
minute
4- If you could not count the respiratory rate easily because of clothes or any
other reason, let the patient lie flat and pretend that you are measuring the apical pulse
or performing cardiac examination while counting the respiratory rate in 30 seconds.
5- Record the results as breathes/ minute and comment on regularity and
difficulty.
Neck pulsations
1- Inspect the neck for pulsations
a) Turn the patient’s head slightly away from the side you are inspecting
b) Raise or lower the bed until you identify the pulsations
c) Confirm the type of pulsation venous vs. arterial by applying the appropriate
maneuvers.
d) If venous pulsations: Identify the highest point of pulsation then measure the
vertical distance of this point above the sternal angle (Venous pressure) and
comment
2) Palpate the carotid pulsations and comment
3) Auscultate the carotid arteries for bruits with the bell of the stethoscope
Ask the patient to take a deep breath and hold it to eliminate breath sounds

The Upper Extremities

The Hands:

a. Appearance of hand and fingers:

b. Nails:
1 Clubbing and its degree
2 Cyanosis:
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 3. Splinter hemorrhages
4. Nail pitting in Psoriasis
5. Nail spooning
c. Temperature and sweating
d. Skin texture, mobility and turgor
e. Capillary refill:
f. Radial pulse examination
g. Tremors:
Examination of the Lower Extremities
1. inspection : color, swelling, nail, skin
2. Palpate the area, feeling carefully for the pulses as well as for adenopathy,
temperature, edema, Capillary Refill
3. For femoral hernia, patient stands and coughs.
Edema:
1. Look around the malleoli,
2. push on the area for several seconds, release, and then gently rub your finger
over that same spot,
3. Note if edema is unilateral or bilateral, pitting or non-pitting, and assess the
level of edema.
4. Full comment: bilat or unilat, extent, pitting or not, painful or not
The Distal Pulses:
a. The Dorsalis Pedis (DP) Artery
b. The Posterior Tibial (PT) Artery:
Compare both sides and comment
Lymph Nodes Examination

A-Cervical LNs:
Inspection:
Palpation:
I - Horizontal Group:
Examine from behind, laterally flex neck towards the site examined, by rolling
with tips of fingers, bilateral at same time
Comment: site, size, number, consistency, tenderness, relation to each other, and
to surrounding structures, overlying skin, and drainage areas.
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 II - Longitudinal Group:
Palpating Anterior Cervical Lymph Nodes
1. Anterior Cervical (both superficial and deep):
On top of and beneath the sternocleidomastoid muscle (SCM) on either side of the
neck, from the angle of the jaw to the top of the clavicle. Ask the patients to
turn their head into your hand while you provide resistance.
2. Posterior Cervical: Extend in a line posterior to the SCMs but in front of the
trapezius,

3. Supra-clavicular:
Method of palpation:
From back:
- Superficial & upper, lower deep cervical LNs.
- Supraclavicular LN with pt arm down and or in waist with valsalva.
From front:
- Deep scalene LNs (bilateral one by one),
- Post Cervical LNs.

B-Axillary LNs:
Inspection: for any visible swelling, LNs, oedema, erythema, red streaks, ulcer
or any skin lesion.
Palpation: Palpation of the Axilla
1-Methods:
Examine the patient from the front:
�
forearm
� into the patient's left axilla
�
� axillary fold
�
�
�
� ,
palpate for the lymph nodes
Palpate the posterior axillary fold from behind
2- Sites: anterior, medial, apical, lateral, and posterior.

C-Epitrochlear LN:
Inspection:
For any visible swelling, LNs, oedema, erythema, red streaks, ulcer or any skin
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lesion.
Palpation:
1-Method:
�
�
aspect of the patient's right elbow. Do the opposite when examining the
left side.
� itrochlear lymph node against
the bone in an antro-posterior direction

D-Inguinal LNs:
Inspection:
For any visible swelling, LNs, oedema, erythema, red streaks, ulcer or any skin
lesion.
Palpation:
1- Method:
i. Pt lie in supine position with abducted externally rotated hip.
ii. Palpate above and below the inguinal ligament
iii. Examine both sides
2- Sites: horizontal along inguinal ligament and vertical along saphenous vein,

E-Popliteal LNs:
Inspection:
For any visible swelling, LNs, oedema, erythema, red streaks, ulcer or any skin
lesion.
Palpation:
1-Method: pt in supine position and hip and knee flexed, and examined by rolling
against lower end of tibia from front or lower end of femur from the back.
2-Site: both popliteal fossa side by side
1-Method: pt in supine position and hip and knee flexed, and examined by rolling against lower e
back.
3-Drainage area: LL
4-Comment:

6
 History taking of patient presenting with fever

STEP / TASK
Getting Ready
• Make sure that the clinic is ready
• Wash and dry hands.
Greet the patient, introduce self and offer a seat. Secure patient's privacy & comfort
• Explain procedure, obtain consent and listen to patient carefully.
• Maintain eye contact
Personal history
Complaint:
• Duration
Fever analysis
• Onset, course, duration
• Character:
• Pattern:
Associated:
 rigors
 shivering
 sweating (in absence of antipyretic)
muscles & joint pains
 presence of toxic symptoms
 Quick review of imp symptoms in diff systems to localize a cause: urinary – throat &
chest – abdomen – cardio – neuromuscular
Past Medical History
• Medical disease:
• Allergy to medications.
• Hospitalization or Intervention
• Canal water exposure and tartar emetic injection.
• Recent travel history: HIV and other infectious diseases.
• Pet/ animal / bird exposure.
• Vaccination history
Past Surgical History
Drug History
Family History
Ideas, concerns and expectations of the patient
Explain the diagnosis to the patient & whether it is serious or not?
Answer any question of patient.
Ask the patient if he has any other questions
Thank your patient

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 Endocrinology Sheet

STEP / TASK Mark

Introduction:
 Explain the need to take a history.
 Gain oral consent from patient.
 Ensure that the patient is comfortable.
Personal History:
Complain
 Patient’s own words
 Onset, course duration
History of present illness
 If suspected Cushing disease:
hyperpigmentation, central obesity, weight gain, striae, ecchymosis, easy bruising, delayed wound
healing, symptoms of DM, acne, hirsutism
 If suspected Acromegaly:
change in face features, as jaw, nose, forehead, changes in voice, excessive facial hair in women,
enlarged tongue, hands, and feet, weight gain, joint pain, muscle weakness
 If suspected hyperthyroidism:
weight loss, palpitations, increased appetite, nervousness, anxiety, irritability, difficulty sleeping,
tremors, sweating, skin thinning, fine, brittle hair, increased sensitivity to heat, changes in bowel
patterns, fatigue, muscle weakness, enlarged thyroid gland (goiter)
 If suspected hypothyroidism:
fatigue, increased sensitivity to cold, muscle weakness, muscle aches, constipation, dry skin, puffy
face, hoarseness, weight gain, pain, stiffness or swelling in joints, enlarged thyroid (goiter),
depression, impaired memory
 If suspected diabetes:
polyuria, polydipsia, polyphagia, unexplained loss of weight, tingling & numbness, diabetic foot
(infection, ulcer), recurrent infection, lower limb odema
Past history
Family history (similar conditions, D.M, dyslipidemia, stroke, CAD)
Psychosocial history
Ideas, concerns and expectations of the patient
Ask the patient if he has any other questions
Thank your patient
Provisional diagnosis (Etiological, anatomical, pathological, functional, complications)

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 Examine a case of Acromegaly
Mark
GETTING READY

• Greeted the patient respectfully and with kindness.

• Introduce himself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient.
• Proper patient positioning .Warm hands

Vital data: (hypertensive)

Face
• Coarse features (big nose, ear, lips)
• Forehead thick supraorbital ridge and skin fold
• Prominent nasolabial fold
• Infraorbital puffiness
• Oily sweat
• Mandibular prognathism and overbite occlusion
• Separated teeth
• Macroglossia
• Field of vision (confrontation test)
• Deep voice
Neck Examination (Skin tags, Goiter)

Hands Examination:
Large hands (spade shaped), thick skin, thick fingers (sausage-shaped), wasting of thenar muscles
(carpal tunnel syndrome), peripheral neuritis, proximal myopathy
Feet Examination:
Osteoarthritis (knee crepitus), peripheral neuritis, proximal myopathy
Abdominal Examination:
Organomegaly (liver and spleen)
Comment:
Total

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 Examine a case of Diabetes
Mark
GETTING READY
• Greeted the patient respectfully and with kindness.
• Introduce himself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient.
• Proper patient positioning .Warm hands
Full General Examination with stress on:
Consciousness, Built (weight – height – BMI – waist – W/H ratio), air hunger (deep breathing),
acetone smell.
Vital data: Blood pressure (both erect and supine)
Eye
(Squint / ptosis, Ophthalmoplegia, Cataract, Arcus senelis and xanthelasma)
Neck
(Carotid pulse and bruit, Goiter)
Skin
(Acanthosis nigricans, Skin & Soft tissue infections, Vitiligo, Insulin injection site)
Upper and Lower Limbs:
dupuytrene contracture, trigger finger, charcot joints, wasting of small muscles of the hand, edema,
peripheral pulsation, skin color, temperature gradient, trophic changes or ulcers, interdigital fungal
infection, glove and stock hypoesthesia, monofilament test, sense of vibration
Comment:
Total

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 Examine a case of Thyroid
Mark
GETTING READY
• Greeted the patient respectfully and with kindness.
• Introduce himself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient.
• Proper patient positioning. Warm hands
General examination with stress on
Vital data: (tachycardia or bradycardia)
Eye:
Inspect:
Lid retraction, Eyelid (puffiness – tremors), Exophthalmos (proptosis) (stand behind sitting patient
and tilt the head backwards or laterally using a ruler or exophthalmometer). Conjunctiva (chemosis
or injection)
Examine: extraocular muscles movement
Confrontation test
Test for convergence

Hand Examination
(Warm, sweaty, Tremors (use a paper sheet?)
Thyroid examination:
The patient is either sitting or standing, looking forwards with relaxed neck muscles and a slightly
extended neck.
Inspection (ask the patient to swallow, protrude the tongue. comment on the size and shape of the
thyroid gland, jerky carotids and overlying skin)
Palpation (Stand behind the patient who should be sitting, Fix the trachea with the left hand, palpate
the right lobe with the right hand (then repeated for the other side), Ask the patient to swallow and
palpate the isthmus (could be also by the anterior approach). Examine the cervical lymph nodes on
both sides. Examine the carotid pulsations on both sides. Comment on: Size, Surface, Consistency
Tenderness, Presence of thrill, Relation to surrounding structures
Percussion: Direct percussion on the sternum (retrosternal dullness)
Auscultation Both lobes of the thyroid (bruit)
Comment:
Total

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 Examine a case of Cushing
Mark
GETTING READY
• Greeted the patient respectfully and with kindness.
• Introduce himself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient.
• Proper patient positioning. Warm hands
General examination with stress on
Vital data: hypertension

Face: Moon face, Plethora, Hirsutism and acne vulgaris in females

Skin:
Skin: thinning over the limbs (visible veins and cigarette paper sign), bruises, hyperpigmentation
Striae rubra
Body fat distribution:
supraclavicular pad of fat, truncal obesity, intersacpular and dorsocervical fat (buffalo hump)
Musculoskeletal & Neurological Examination:
short stature, osteoporosis (tender spine), proximal myopathy, peripheral neuropathy
Comment:
Total

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 Examine a case of Addison disease
Mark
GETTING READY
• Greeted the patient respectfully and with kindness.
• Introduce himself in a warm, friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient.
• Proper patient positioning. Warm hands
General examination with stress on
Vital data: Blood Pressure (erect and supine posture)
Skin Hyperpigmentation:
in cheeks and forehead and v area (sun exposed areas), palm creases, hand knuckles, buccal mucosa
and gums, scars (recent rather than old), friction areas (e.g. elbow and knees)
Skin Hypopigmentation:
areas of vitiligo (Nipples and areola

Examination:
of pubic and axillary hair
Comment:
Total

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 Cardiac History Taking

STEP / TASK Mark

Introduction:
 Explain the need to take a history.
 Gain consent from patient.
 Ensure that the patient is comfortable.
Personal History:
Complaint
 Patient’s own words
 Onset, course and duration
History of present illness
 Dyspnea (onset, course, duration, frequency, grade), orthopnea, PND
 Palpitation (onset, offset, duration, regularity, associated syncope, precipitated by,
relieved by, associated symptoms)
 Chest pain (onset, site, radiation, character, duration, associations, exacerbating/relieving
factors, severity)
 Syncope (position prior to event, preceding activity, loss of consciousness and associated
symptoms, duration of attack, previous attacks)
 Cough (onset, persistent or episodic, frequency, dry or productive, special character)
 Expectoration (amount, color, consistency, odor, relation to certain posture)
 Hemoptysis (frank , blood tinged, frothy, amount)
 Peripheral edema (onset , course , duration, unilateral or bilateral, pain, precipitating
factor, associated symptoms)
 Symptoms related to hypertension (headache, dizziness, burring of vision, vertigo)
 Symptoms related to peripheral embolism (sudden blindness, hemiplegia, hematuria)
 History of peripheral vascular disease (onset, course, duration, site, intermittent
claudication, Raynaud’s phenomenon)
 Fever (onset , course, duration, character, pattern, associated symptoms)
 Review of other systems (pain in right hypochondrium……)
Past history (hypertension, D.M, valve replacement, CABG, rheumatic fever)
Drug history
Family history (D.M, dyslipidemia, stroke, CAD, sudden cardiac death)
Psychosocial history
Thank your patient
Provisional diagnosis (Etiological, anatomical, pathological, functional, complications)

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 Examine cardiovascular system
Mark
GETTING READY
• Greeted the patient respectfully and with kindness.
• Introduce himself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient. Warm hands.
• Proper patient positioning (supine position with the upper body elevated 30 to 45 degrees. If
orthopnic; semi-sitting position. Expose the patient's chest well.
General examination with stress on
Vital data: Pulse, Blood Pressure

Neck: inspect jugular venous pulsation, carotid pulsations, palpate the carotid pulsation, auscultate the carotid
arteries (bruit)
Local Cardiac Examination
Inspection:
Look tangentially, from the foot end of the patient for precordial bulge, dilated veins, scars of previous
operation (e.g. valvotomy, mid sternotomy, etc).
Look tangentially, from the side of the patient for apical and other pulsations (Suprasternal area, Aortic area,
Pulmonary area, Parasternal area, Epigastrium

Palpation: Ask pt. if any part is tender, examine that last.

Apex: (Site, Character, Thrill).
Left parasternal area using the palmar aspect for thrills.
parasternal heave Using palmar aspect at the base of metacarpals
Palpable second sound Tips of the fingers in the second left intercostal space to elicit (diastolic shock).
Epigastric: Place the palm of the right hand on the epigastrium and slide the fingers under the rib cage

Auscultation:
The first aortic area, pulmonary area , second aortic area, left sternal border, Tricuspid area, mitral
area. Move to axilla.
Listen first with the diaphragm for high pitched sounds. Listen by the cone for low pitched sounds
Time with the carotid pulse
Ask the patient to roll onto his left side. Identify the apical impulse. Auscultate the apex with the bell. Ask
the patient to sit up, lean forward, exhale completely and hold breath in expiration. Listen to aortic areas down
the left sternal border to the apex and evaluate the splitting of the second sound in the pulmonary area
Auscultate the carotids and the lung bases
Comment:
First and second heart sounds.
Murmur. If present (timing, character, intensity, area of maximum intensity, propagation, Relation to
respiration, Relation to position, Relation to exercise.
Comment:
Total
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 Chest History Taking
STEP / TASK Mark
Introduction:
 Explain the need to take a history.
 Gain consent from patient.
 Ensure that the patient is comfortable.
Personal History:
Complaint
 Patient’s own words
 Onset, course and duration
History of present illness
 Cough (onset, duration, special character, dry or productive, short or paroxysmal)
 Expectoration (amount, color, odor, aspect, relation to posture)
 Hemoptysis (duration, frank blood or blood tinged, amount)
 Dyspnea (onset, course, duration, type of dyspnea, frequency, precipitated and relieved
by, grade)
 Chest pain (onset, site, radiation, character, duration, aggravating and relieving factors,
associated symptoms)
 Asthmatic attacks (time, duration, precipitating and relieving factors, need for hospital
admission)
 Mediastinal compression symptoms (edema of the face, puffiness of eyelids,
dysphagia, hoarseness of voice)
 Toxic manifestations (loss of appetite, loss of weight, night fever, night sweating)
 Edema of the lower limb (onset , course , duration, unilateral or bilateral, pain,
precipitating factor)
 Review of other systems (pain in right hypochondrium……)
Past history (similar attacks, rheumatic fever, TB, bilharziasis, previous hospital admission)
Drug history (allergy, self-abuse of analgesics or addictive drugs)
Family history (similar condition, TB, diabetes, hypertension, genetic diseases as asthma,
cystic fibrosis)
Psychosocial history
Thank your patient
Provisional diagnosis (Etiological, anatomical, pathological, functional, complications)

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 Examine respiratory system
Mark
GETTING READY
• Greeted the patient. Introduce yourself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient. Warm hands.
• Proper patient positioning (patient lie supine, lower his gown to waist level)
Inspection:
Stand at the feet of patient: shape of the chest, symmetry of the chest on both sides, breathing movement,
accessory muscle use, retraction of lower intercostal spaces.
Stand to the right of patient and look tangentially for apical and epigastric pulsations,
Inspect chest wall and skin for swelling, scars, skin eruption or engorged veins.
Palpation:
Upper lung zone:
Middle lung zone
Lower lung zone
Palpable rhonchi, pleural rub or chest wall tenderness,
Tactile vocal fremitus (Place the palm of hand over chest wall in the direction of bronchial tree away from
midline with comparison. Ask the patient to repeat the words ―44‖ in Arabic)
Tracheal examination: Ask the patient to sit up with the head straight.
Tracheal position ―Trill‘s sign.
Tracheal shift (Insert the index finger in horizontal position in the pouch between the medial end of
sternomastoid and the lateral aspect of trachea with comparison).
Check the cricosternal distances.
Tracheal descent (place the tip of the index finger on the thyroid cartilage during inspiration to observe
its descent)
Percussion:
Light percussion
Krönig’s isthmus
Percuss clavicles directly (over medial third)
infraclavicular regions, parasternal lines, midclavicular lines, anterior axillary lines, middle axillary lines,
posterior axillary lines right and left, from fourth space to the eighth space with comparison. Comment on
dullness found.
Bare area of the heart (Place the left hand in the left 4th and the 5th spaces between midline and parasternal
line.
Heavy percussion: Upper border of the liver.
Tidal percussion: If any infrascapular dullness was found, fix the left hand over it and ask the patient to take
a deep breath and hold it then percuss again.

Auscultation:
Both midclavicular lines right & left, from second space to the sixth space, both midaxillary lines right & left,

17
from fourth space to eighth space with comparison
Ask the patient to say ‗ 44 ‘and auscultate both lines right & left,
Comment: breath sounds character and intensity, adventitious sounds (wheeze, crepitations), type of wheeze
(inspiratory or expiratory, localized or generalized) , type of crepitation (fine or coarse, change with cough),
vocal resonance
Examination of the posterior chest wall.
Inspection
Palpation
Percussion
Auscultation
Comment:
Total

18
 Gastroenterology History Taking
STEP / TASK Mark

Introduction:
 Explain the need to take a history.
 Gain oral consent from patient.
 Ensure that the patient is comfortable.
Personal History:
Complain
History of present illness
Upper GI symptoms:
• Appetite (loss of appetite, increased appetite, nausea)
• Vomiting (onset, course, duration. relation to food, relation to posture, preceded by nausea or not,
amount, content, color)
• Hematemesis (onset, course, duration, associated melena, amount, color, associated symptoms e.g pain,
postural hypotension, bleeding tendency)
• Halitosis, xerostomia, dysphagia, belching, water brash, ptyalism.
 Epigastric pain (onset, course , duration, what increase, what decrease, character, radiation)
Lower GIT symptoms:-
 Diarrhea (onset, course, duration, frequency, character, amount, associated symptoms e.g. abdominal
pain, vomiting, fever, toxic symptoms, manifestations of malabsorption, arthralgia)
 Constipation.
 Dysentery.
 Flatulence.
 Bleeding per rectum.
 Lower abdominal pain
 Melena
 Painful defecation
Hepatobiliary symptoms:-
 Biliary colic
 Jaundice (Onset, Course, duration, Color of Urine and stool, associated symptoms e.g. Anorexia, nausea,
vomiting, Fever, Bleeding tendency, Pain, Pruritis)
• edema of lower limb, wasting muscle, low grade fever, hand tremors, gynecomastia, decrease or loss
libido, bleeding tendency, abdominal enlargement, bad mouth odor, disturbed conscious level
Past history (episodes of abdominal pain, hospital admissions and surgery, blood Transfusion, bilharzasis,
dental Procedures)
Drug history (allergy, self-abuse of analgesics, addictive drugs, steroids, OCPs)
Family history (similar condition, colon cancer, irritable bowel syndrome, inflammatory bowel disease,
jaundice, peptic ulceration, and polyps)
Psychosocial history
Thank your patient
Provisional diagnosis (Etiological, anatomical, pathological, functional, complications)

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 Examine gastrointestinal system
Mark
GETTING READY
• Greeted the patient. Introduce yourself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient. Warm hands.
• Proper patient positioning (undress from the symphysis pubis to just above the xiphoid process,
allowing the patient to cover with a clean sheet. Ask the patient to lie flat on the back with the arms at
side and legs extended. Or ask the patient to flex the hips to 45° and the knees to 90° in order to relax
the abdominal muscle).
General Examination:
Level of consciousness, Decubitus and fascies,
Vital data (Blood pressure, pulse, temperature)
Complexion (Pallor, Jaundice, Cyanosis), LN examination, U.L. (clubbing, flabbing tremors, palmar erythema).
L.L. (edema, clubbing). Head & Neck (wasting of temporalis, thyroid swelling). Spider naevi.
Signs of Hypovitaminosis.
Local Examination:
Inspection:
Look from the foot end of the patient tangentially and comment on:
Contour of the central abdomen, Localized enlargement, Abdominal movements with respiration, Pulsations,
Visible peristalsis, Costal margin, Divarication of recti (ask the patient to rise from supine position without
using his arms), Umbilicus (site, shape, discharge, pigmentation, ulceration, infiltration), Hernial orifices
(elicited by coughing while patient is standing), Skin (pigmentations, scars, striae, sinuses, hair distribution,
dilated veins: determine the direction of the flow by placing two fingers on the vein, sliding one finger along
the vein to empty it and then releasing one finger and watching to see which way the empty segment fills).
Palpation: Ask the patient whether there is a painful area or a mass.
Superficial palpation: Start in right iliac fossa palpating lightly anticlockwise to end in the right lumbar area.
Palpate each quadrant lightly to detect tenderness, rigidity, or superficial swelling.
In case of Swelling: ask the patient to contract the abdominal wall muscles by raising the head
Deep palpation:
Liver: Place right hand on the right iliac fossa in mid clavicular line resting transversely parallel to the costal
margin or Placed with fingers pointing towards the head of the patient. Ask the patient to take a deep breath.
Keep the hand still during inspiration. Ask the patient to expire, slide the hand a little nearer to the right costal
margin till the lower border of the right lobe of the liver is palpated. Put the hand in the midline and repeat the
above steps till the lower border of the left lobe of the liver is palpated. Put one hand on the liver anteriorly and
the other hand at the back. Ask the patient to hold his breath and feel for pulsation
Spleen: Start from right iliac fossa with the tips of the examining hand directed towards left axilla, move
toward the left hypochondrium until the spleen is felt. Bimanual examination: Start from right iliac fossa with
the tips of the examining hand directed towards the left axilla Place the left hand over the lateral aspect of the
left costal margin, exerting a certain amount of compression and move toward the left hypochondrium until the
spleen is felt. Right lateral position method: Ask the patient to turn to the right side, Insinuate the hand below
the costal margin Ask the patient to take a deep breath Press till the lower edge of the spleen is felt Hooking

20
method: Stand on the left side of the patient‘s head Place the fingers of both hands over the costal margin.
Instruct the patient to take deep breath.
Right kidney: Put the left hand behind the patient's right loin (between the last rib and the iliac crest), Lift the
loin and the kidney forward, Put the right hand on the right lumbar region just above the anterior superior iliac
spine and ask the patient to take a deep breath. During expiration push the right hand deeply but gently and
keep it during inspiration. Repeat as the patient takes his breath. Left kidney: Repeat the same procedure on the
left side by either standing on the patient's left side or by leaning across the patient, Put the left hand in the left
loin and feel the kidney with the right hand.
Gall bladder, Aorta and para-aortic glands, Urinary bladder. Rt & Lt lower quadrants. If a swelling is
palpable, illicit its features
Tense ascites (dipping method): a quick pressure of the tips of the fingers over the region where the edge of
the organ is expected

Percussion:
Liver: upper border of the liver by heavy percussion starting from the 2nd intercostal space opposite the
sternocostal junction. Percuss down along each inter-costal space in the MCL; when reaching the dullness
asked the patient to take a deep breath and hold it. Confirm by tidal percussion. Measure the distance
between the upper border (by percussion) and lower border (by palpation) in the right mid-clavicular line.
Spleen: Traube space. Percuss the anterior axillary line 8-9th space while patient supine. Ask the patient to
take a deep inspiration and repeat percussion
Ascites: Place the fingers parallel to the flanks (in the longitudinal axis). Start percussion from the midline
down to the flank till eliciting a dull tone. On detecting dullness, ask the patient to turn to the opposite side,
while keeping the examining hand over the exact site of dullness. Keep the hand in position till the patient
rests on the opposite side, Percuss again in this new position. Repeat percussion on the other side of the
abdomen. Knee elbow position (If shifting dullness is negative): Percuss around the umbilicus while the
patient is kneeling in the knee-elbow position. Fluid thrill: Instruct the patient to lie in the supine position
Place one hand flat over the lumbar region on one side Get the patient to put the hand in the midline of the
abdomen. Tap or flick the opposite lumbar region
Auscultation: intestinal sounds, venous hum in the epigastrium, rub over the liver and spleen, renal artery
bruit (on the left and right sides of the epigastrium or in the back below the last rib), succussion splash, scratch
sign to detect hepatomegaly
Examination of the back:
Inspect for any swellings, deformities or scars.
Palpate for edema over the sacrum, tenderness in the renal angels, tenderness over vertebrae Percuss the renal
angle.
Auscultate the renal angles for bruit.
Comment:
Total

21
 Hematology History Taking Checklist
STEP/TASK Mark

Introduction:

 Explain the need to take a history

 Gain consent from patient
 Ensure that the patient is comfortable
Personal History:

Complaint + duration

History of present illness:

 Symptoms of anemia: headache, malaise, lack of concentration, dyspnea

with effort, palpit, dizziness and fainting episodes…

*If positive, ask about dietary habits, bowel habits, bleeding per orifices
,tingling and numbness of hand and/or foot, jaundice, and symptoms of
bone marrow suppression,
*LEUCOPENIA: eg. recurrent chest infection, skin abscess
*THROMBOCYTOPENIA: bleeding: site, onset, need for blood transfusion

 Splenomegaly: left hypochondrial pain, early satiety

 Lymph node enlargement
 B –symptoms: anorexia, weight loss, night fever or night sweating
 Symptoms of other systems

Past History:

Drug history

Family History: consanguinity, DM, HTN, similar condition

Psychosocial History: patient’s ideas, concerns & expectations

Thank your patient

Provisional diagnosis: etiological, anatomical, pathological, functional, complications

22
 Nephrology Sheet
STEP / TASK Mark

Introduction:
 Explain the need to take a history.
 Gain oral consent from patient.
 Ensure that the patient is comfortable.
Personal History:
Complain
History of present illness
 Uremic symptoms (Fatigue, Edema in the face and legs, dyspnea, Orthopnea, Nausea
with/without vomiting, Anorexia, Pruritus, Restless legs, Myoclonic jerks, Seizures, Bony
aches)
 Symptoms of nephrotic syndrome (Edema in the face and legs, Foamy urine, Weight gain)
 Complications of nephrotic syndrome (Venous thromboembolism, Poor nutrition, Infections)
 Symptoms of nephritic syndrome (Edema in the face and legs, oliguria, Hematuria,
Hypertension, Malaise, Symptoms of uremia)
 Upper urinary tract infection (Upper back and flank pain, fever, Shaking and chills, Nausea,
Vomiting)
 Lower urinary tract infection (Pelvic pressure, Lower abdomen discomfort, Frequent, painful
urination, Cloudy urine or red, bright pink or cola-colored urine)
 Obstructive symptoms (Urgency, Hesitancy, Dribbling, Nocturia)
 Voiding symptoms (Urinary retention, Urinary incontinence, Polyuria)
Past history: Diabetes mellitus, Hypertension, Glomerulonephropathie, Reflux nephropathy,
Polycystic kidney disease, Autoimmune conditions and monoclonal gammopathy disorders, Past
acute kidney injury, Recurrent urinary tract infections, Renal calculi, dialysis sessions
Drug history (Potential nephrotoxic medications, erythropoietin, phosphate binders,
Immunosuppressive agents)
Family history (similar condition, autosomal dominant polycystic kidney disease or Alport
syndrome)
Psychosocial history
Thank your patient
Provisional diagnosis (Etiological, anatomical, pathological, functional, complications)

23
 Examine a case of nephrology
Mark
GETTING READY
• Greeted the patient. Introduce yourself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient. Warm hands.
• Proper patient positioning (undress from the symphysis pubis to just above the xiphoid process,
allowing the patient to cover with a clean sheet. Ask the patient to lie flat on the back with the
arms at side and legs extended. Or ask the patient to flex the hips to 45° and the knees to 90° in
order to relax the abdominal muscles)
General examination:
Pallor and wasting, yellow-brown colored face.
Vital signs (Blood pressure, pulse, temperature, respiratory rate)
Neck: Elevated JVP, Dialysis catheter
Upper limb examinations: AVF (Thrill and bruit).
Skin signs : Xerosis, Hyperpigmentation, Excoriation, Uremic frost, Petechiae or ecchymoses,
Lindsay’s nails
Lower limb examination: lower limb edema (Unilateral or bilateral), skin changes
Chest examination
Inspection : Venous collaterals
Percussion: Dullness (pleural effusion)
Auscultation: pleuritic friction rubs, inspiratory crackles over posterior lung fields decreased breath
sounds at lung bases
Cardiac examination: pericardial friction rub, distant heart sounds, hemic murmur at base of heart
Abdominal examination
Inspection: visible fullness of the upper abdomen, Abdominal striae
Palpation: Costovertebral tenderness
Palpation of left kidney: Place the right hand anteriorly in the left lumbar region while the left hand
is placed posteriorly in the left loin. Ask the patient to take a deep breath in, press the left hand
forward and the right hand backward, upward and inward. When palpable (rounded firm swelling
between both right and left hands bimanually palpable) can be pushed from one hand to the other
Palpation of right kidney: Place the right hand horizontally in the right lumbar region anteriorly
with the left hand placed posteriorly in the right loin. Push forwards with the left hand, press the right
hand inward and upward and ask the patient to take a deep breath in. The lower pole of the right
kidney (commonly palpable in thin patients) is felt as a smooth, rounded swelling which descends on
inspiration and is bimanually palpable and may be ‘ballotted’.
Percussion: Bilateral shifting dullness, Suprapubic mass
Auscultation: A soft, lateralizing bruit in the epigastrium or the flank
Neurologic examination: altered mental status (confusion, drowsiness, or inattention), slurred speech.
asterixis, myoclonus, sensory deficits, motor deficits.
Comment:
Total
24
 Neurology Sheet
STEP / TASK Mark

Introduction:
 Explain the need to take a history.
 Gain oral consent from patient.
 Ensure that the patient is comfortable.
Personal History:
Full name, Age, Gender, Residence, Marital state, Occupation, Handedness, Special habits of
medical importance (smoking, alcohol, drug history or allergy)
Complaint
Family history (similar condition, consanguinity, other neurological or psychiatric illness in the
family)
Past history (similar conditions, Fever or trauma of neurological significance, Relevant medical
illness, Relevant surgeries, Drug history, Recent vaccination, blood transfusion, contraceptive pills)
History of present illness
• Analysis of the complaints
• Define the duration of each symptom and its fate (course)
• Headache, disturbed consciousness, seizures and speech.
• Cranial nerves (diminution of visual acuity, seeing two images beside each other, deviation
of eyeballs, deviation of angle of mouth on one side, difficulty in swallowing, difficulty in
articulation of speech).
• Motor system (weakness and distribution, tone changes, swaying of gait to either side,
tremor when moving limbs).
• Sensory system (decreased sensation, tingling sensation, numbness).
• Sphincter control.
• Hypothalamic manifestations.
• Symptoms of other systems 'affection.
Psychosocial history
Thank your patient
Provisional diagnosis:
WHERE IS THE LESION (Physio-anatomical diagnosis by either focal, multifocal, disseminated
or systemic
WHAT IS THE LESION? (Pathological diagnosis by either Vascular diseases, Traumatic diseases,
Inflammatory diseases, Space occupying diseases, or Metabolic, Toxic and Hereditary diseases.

25
 Examine Neurological system
Mark
GETTING READY
• Greeted the patient. Introduce yourself in a friendly manner.
• Explained the procedure to the patient.
• Stood by the right side of the patient.
• Proper patient positioning. Warm hands.
Speech Examination: take history from the patient or from an informant. Establish if right or left handed.
Assess spontaneous speech. Assess understanding by asking questions, simple and complicated commands.
Assess word finding ability and naming by asking the patient to name familiar objects Assess the ability to
articulate the words properly
Comment on aphasia (expressive, receptive, global or nominal aphasia)
Comment on dysarthria (e.g. slurred, staccato or nasal intonation of speech)
Cranial nerves:
I (olfactory nerve): Describe the procedure to the patient. Ask the patient to close both eyes. Examine one
nostril at each time using a non-pungent material and ask the patient about its nature
II (optic nerve)
Visual acuity: Position the patient 6 meters. The patient cover one eye at a time. Assess counting finger, hand
movement or perception of light at which distance. Repeat for the other eye
Visual field: Position the patient at 50 cm and at eye level with you. Ask the patient to fix eyes. Cover the
untested eyes. Place index finger at half distance beyond limits of field of vision. Move the wiggling finger
towards the center of vision until it is perceived by the patient. Test the four quadrants. Repeat for the other
eye
Pupillary light reflex. Ask the patient to look into the distance. Shine a bright light obliquely into each pupil
in turn. Look for the change of pupil size in the same eye and in the other eye
Accommodation reflex: Place finger about 10 cm from the patient‘s nose. Ask the patient to alternatively
look into the distance and at the finger.
III, IV and VI (occulomotor, trochlear, abducent nerves): Inspect for ptosis and squint. Instruct the patient
not to move his head and to follow the finger with eyes open. Place your finger about 25 cm from patient and
make a large ―H checking for all 6 cardinal positions of gaze. Conjugate eye movement: Ask the patient to
follow your finger with both eyes open while moving it slowly and rapidly at horizontal and vertical planes.
Comment: gaze palsy, internuclear ophthalmoplegia or nystagmus
V (trigeminal nerve)
Motor: Ask the patient to clench his teeth and palpate the temporalis and masseter muscles. Ask the patient to
move jaw to the contra lateral side and to open mouth against resistance
Sensory: Compare pain sensation at the 3 sensory divisions on both sides, the sensory divisions on the same
side and then within each division.
Corneal reflex: Ask the patient to look up and away. Touch the cornea lightly with a fine wisp of cotton.
Look for the normal blink reaction of both eyes. Repeat on the other side
Jaw reflex: Ask the patient to hang the jaw freely. Tap your index finger placed on the chin of the patient (jaw
closure)
VII (facial nerve)
Motor: Inspect the face for symmetry Ask patient to raise eyebrows, close eyes tightly against resistance,
smile showing teeth and blow cheeks. Comment: weakness or asymmetry
Sensory: Ask the patient to protrude his tongue while eyes are closed, Apply salt or sugar in the anterior part
of tongue, Instruct the patient not to withdraw tongue unless identifying the nature of substance
Glabellar reflex: Tap the region between the eyebrows while the patient is looking to your finger placed
about 25 cm away from patient‘s head
26
VIII (vestibulocochlear nerve)
Voice test: Stand beside the patient at about 50 cm. Whisper at very low voice, ask the patient to repeat what
is said. Finger friction sound or watch tick may be used. Compare both sides
Weber test: Use 512 Hz tuning fork, start vibration. Place the base on the patient‘s forehead and ask the
patient where the sound appear coming from
Rinne test: Use 512 Hz tuning fork, start vibration. Place the base on the mastoid bone behind the ear till
sound disappears. Hold the end of fork near the patient‘s ear, ask if hearing vibrating sound. Repeat on the
other side
Finger pointing test: Instruct the patient to outstretch his hand while pointing both index fingers. Place your
index fingers opposite to the patient‘s ones. Ask the patient to close eyes. Comment on past pointing
IX and X (glossopharyngeal, vagus nerves): Ask patient to say ―ah and observe both sides of the palatal
arch and the position of uvula. Palatal reflex: Place a torch over tongue depressor in one hand and advance
them in the patient‘s mouth to see pharynx. Touch the right and left peritonsillar area gently with tongue
depressor. Comment: elevation of the palate and uvula
Gag reflex: Touch the posterior pharyngeal wall and assess the response
XI (accessory nerve): Stand behind the patient while sitting on a chair. Look for atrophy or asymmetry of the
trapezius muscles. Place hands over both shoulders and ask the patient to elevate shoulders against resistance.
Place hand on the patient‘s mandible at one side and ask the patient to push it against resistance, test the
sternomastoid muscle for contour and power
XII (hypoglossal nerve): Observe the tongue as it lies in the mouth, comment on atrophy or fasciculation.
Ask the patient to protrude tongue and observe deviation. Place finger over the patient's cheek and ask to press
by his tongue.
Motor Examination
State: atrophy or hypertrophy, compare both upper and lower limbs sides by inspection, palpation and
measurement. Inspect for fasciculation and tap over the muscles to elicit them.
Tone: Assess tone around joints of upper and lower limbs and compare to the other side, by passive movement
and side to side shaking. Comment: hypotonia, spasticity or rigidity
Power: finger abduction, opposition, hand grip, flexion and extension at wrist, flexion and extension at elbow,
flexion, extension, abduction and adduction at shoulder, flexion and extension of big toe, flexion and
extension of all toes, flexion, extension, eversion and inversion of ankle, flexion and extension of knee,
flexion, extension, abductors and adductors of hip, trunk muscles
Coordination and gait: upper limb ataxia via finger to nose test (instruct the patient to bring index finger to
tip of nose), ask the patient to perform rapid alternative movements (rapid supination and pronation). Test for
lower limb ataxia via heel to knee test (instruct the patient to place the heel of one foot on the knee of the other
leg then slide the heel down from the knee to the instep of the leg). Assess stance and gait via asking the
patient to walk heel-to-toe in a straight line.
Involuntary movements. Comment: any involuntary movements if present
Reflexes
Deep reflexes examination
Brachioradialis reflex: patient rest the forearm, tap the radius about 1-2 inches above the wrist with the reflex
hammer
Biceps reflex: Place your index finger firmly on biceps tendon. Tap the finger with the reflex hammer
Triceps reflex: Support the upper arm and let the forearm hang free. Tap the triceps tendon above the elbow
with the reflex hammer
Ankle reflex: Place the ankle over the other leg with slight ankle dorsiflexion and eversion. Tap the Achilles
tendon with the reflex hammer
Knee reflex: Ask the patient to allow the leg to hang down or support the half bent knee on your arm while the
patient is supine. Tap the quadriceps tendon just below the patella with the reflex hammer
Superficial reflexes

27
Abdominal reflex: Scratch the abdominal skin rapidly, not too hard with a needle form the side to the middle
at 3 levels
Planter reflex: Stroke the lateral edge of the sole of foot starting from the heel, heavily and slowly using a
blunt object such as key
Sensory Examination
Superficial sensations: Use a pin prick, Set a reference point on the forehead and compare it with areas
over the extremities within the same side. Compare symmetrical areas on both sides. Compare distal and
proximal areas of the extremities. Test for superficial sensory level. Compare around the limb in levels to
test for dermatome sensory loss
Deep sensations
Vibration sense: Use 128 Hz tuning fork. Stroke the tuning fork and apply it over the patient‘s clavicle to
set a reference point. Apply the tuning fork over the bony prominences in the extremities, and compare it to
that of reference point. Compare the distal and proximal bony prominences (malleoli, patella, iliac crest in
lower limbs and styloid process of radius, olecranon process in upper limbs). Test for deep sensory level by
placing the tuning fork over the vertebral spine processes
Sense of movement: Hold the patient‘s big toe between your thumb and index finger and teach the patient
the different positions of the toe. Ask the patient to close eyes. Move the toe up and down and ask the
patient to determine if the thumb is moving. If it is impaired, move proximally to test the ankle joint. Test
the fingers in similar fashion
Sense of position: Grasp the patient‘s big toe and teach the patient ―up and ―down with the patient‘s
eyes closed, ask the patient to identify the direction of the toe. Test the fingers in similar fashion.
Romberg‘s sign: Ask the patient to stand then close eyes while you are behind him
Cortical sensations: Tactile localization (Ask the patient to localize one point of pin prick). Tactile
discrimination (Use an opened paper clip to touch the patient‘s finger pads in 2 places simultaneously, Ask
the patient to identify it one or two, Determine the minimal distance at which the patient can discriminate).
.Stereognosis (Ask the patient to close eyes, Place a familiar object in the patient‘s hand then ask the
patient to tell what it is)
Examination of spine and cranium: Inspect and palpate skull and spinal cord, and describe any detected
abnormality. Meningeal irritation signs (neck rigidity, Leg raising test)
Examination of sphincters: Examine bladder fullness by percussion to detect supra pubic dullness (unless the
patient is catheterized)
Comment:
Total

28
 Rheumatology History Taking Checklist

STEP / TASK Mark

Introduction:
 Explain the need to take a history.
 Gain consent from patient.
 Ensure that the patient is comfortable.
Personal history
Complaint:

 Patient’s own words

 Onset, course and duration
History of present illness

• Restricted range of movement in one or all directions

• Onset and duration of arthritis (Acute or Chronic)
• Symptoms of joint inflammation to differentiate arthritis from arthralgia
• Morning stiffness
• Number of joints involved at the beginning.
• Sequence of joint involvement
• Distribution of joint involvement
Extra articular manifestations:
• Proximal muscle weakness
• Generalized constitutional symptoms
• Skin manifestations
• Nail changes
• Eye manifestations
• CNS manifestations
• Cardiopulmonary manifestations
• GIT manifestations
• Genitourinary manifestations
• Renal manifestations
• Hematological manifestations
• Alarm symptoms
Past history
Drug history
Family history
Psychosocial history
Thank your patient
Provisional diagnosis (Etiological, anatomical, pathological, functional, complications)

29
 Rheumatological examination of hands and wrists
GETTING READY Mark
• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Inspection:
inspect both hands & wrists for:
 Swelling,
 Deformity,
 Nodule (heberden's nodes, Bouchard nod, etc),
 Muscle wasting,
 Skin abnormality
 Nail abnormality.
Palpation:-
• Palpate the hand for tenderness, synovial thickening, increased warmth and sweating.
• Perform Metacarpal squeeze test
• Palpate Metacarpophalangeal joints, proximal interphalangeal joints, Distal interphalangeal,
joints.
•
• Compare both sides
• Wrist joint palpation for tenderness, synovial thickening
•
• Compare both sides

Movement:
• Ask the patient to open and spread the fingers of both sides
• close the fingers (power grip), of both sides
• To pinch the tip of index finger and thumb (precision pinch) of both sides and feel its power
• Compare active with passive if active range limited,
• Ask the patient to put his hands together in the position of prayer and then to lower the hands
keeping the palms together.

• Ask the patient to place the back of his hands together and to raise the arms upwards.

30
 Rheumatological examination of the elbows
GETTING READY Mark
• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Inspection:
inspect both elbows for:
 Swelling,
 Deformity,
 Nodule
 Muscle wasting,
 Skin abnormality
Palpation:-
 tenderness,
 swelling
 Increased warmth.
 Compare both sides
Movement:
 Instruct the patient to bend and straighten both elbows simultaneously (0-150°),
 With elbows flexed to 90° to turn hands palm up (supination 0-90°) and then palms down
(pronation 0-90°).
 Compare active with passive if active range limited

31
 Rheumatological examination of the shoulders
GETTING READY Mark
• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Inspection:
inspect both shoulders for:
 Deformity,
 Nodule
 Muscle wasting,
 Skin abnormality from front and back
Palpation:-
 Palpate the Sternoclavicular joint
 acromioclvicular joint
 genohumeral joints

Palpate for tenderness, swelling, temperature or crepitus.

Palpate both shoulder joints in a systematic approach.

Movement:
 Ask the patient to put both hands behind the head with elbows pointing laterally (flexion,
abduction and external rotation),

 To put the arms down and reach up behind the back (extension, adduction and full internal
rotation

 Compare active with passive if active range limited

32
 Rheumatological examination of ankles and feet
GETTING READY Mark
• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Inspection:
Inspect both ankles and feet for:
 swelling
 Deformity,
 Nodule
 Muscle wasting,
 Skin abnormality
 Nails abnormality
Palpation:-

Palpate the joints for

 tenderness,
 swelling
 Increased warmth.
 Perform Metatarsal squeeze test.
 Compare both sides

Movement:
 Ask the patient to dorsiflex (20°) and plantar flex (30°) each ankle.
 Passively evert (10°) and invert (20°) the subtalar joints with the ankles in neutral position.
 Flex and extend the MTP joints
 Compare active with passive if active range limited

33
 Rheumatological examination of the knees
GETTING READY Mark
• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Inspection:
inspect both knee joints for:
 swelling
 Deformity,
 Muscle wasting,
 Skin abnormality
Palpation:-

Palpate the joints for

 tenderness,
 swelling
 Increased warmth.
 Compare both sides

Examine for knee effusion

 Patellar tap test:

 Bulge test (massage test)

Movement:
 Ask the patient to flex each knee in turn and observe the range of movement (0-150°) and any
signs of pain.
 Ask the patient straightens each knee; place a hand on the knee to feel the crepitus.
 Compare active with passive if active range limited

34
 Rheumatological examination of the hip

GETTING READY Mark

• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Palpation:-
Palpate the greater trochanter area.
Compare both sides

Movement:
• flexion
• abduction
• adduction
• internal rotation
• external rotation
• extension
• compare both sides

Examine the temporomandibular joint

GETTING READY Mark

• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Palpation:-

Place first two fingers of each hand in front of tragus of ear and instruct patient to open and close
mouth

35
 Examination of the spine and posture

GETTING READY Mark

• Greeted the patient respectfully and with kindness.
• Introduced him/herself to the patient.
• Explained the procedure to the patient.
• Stood by the right side of the patient
• Wash your hands
Inspection:
Inspect the standing patient's spine and posture from behind and the side for:
 abnormal kyphosis
 or lordosis
 or flattening of the longitudinal arch of the foot.

Palpation:-

Palpate the spine for

 tenderness
Movement:
Cervical spine:
 Instructed the patient to try to touch the chest with the chin
 Asked the patient to move the head backward and to look up
 Ask the patient to look right, left, and then tilt the head sideways aiming to touch each ear
on the shoulder.
Thoracic spines
 Measure the chest expansion by a tape at the level of nipple.
Lumbar spine :
 Lumbar flexion,
 Lumbar extension
 Lateral lumbar flexion (both sides)
 Thoracolumbar rotation
Schober's Test
examines curve of spine from upper thoracic to sacrum

36