Physical Exam Reference

Formative miniCEX
Contact details
Australian College of Rural and Remote Medicine
Level 2, 410 Queen Street
GPO Box 2507
Brisbane QLD 4001
Ph: 07 3105 8200 Fax: 07 3105 8299
Website: [Link]
ABN: 12 078 081 848

Copyright
© Australian College of Rural and Remote Medicine 2015. All rights reserved. No part of this
document may be reproduced by any means or in any form without express permission in writing
from the Australian College of Rural and Remote Medicine.
Version: 01/15

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Physical Exam Reference for ACRRM formative miniCEX
Contents

Adults.............................................................................................................................................. 3
Physical Examination of the Respiratory System ......................................................................... 4
Physical Examination of the Cardiovascular System ................................................................... 5
Physical Examination of the Gastrointestinal System .................................................................. 7
Physical Examination of the Endocrine System ........................................................................... 9
Physical Examination of the Nervous System ............................................................................ 10
Physical Examination of the Cervical Spine ............................................................................... 10
Physical Examination of the Shoulder ....................................................................................... 11
Physical Examination of the Knee ............................................................................................. 12
Physical Examination of the thoracic and lumbar spine ............................................................. 13
Mental State Examination .......................................................................................................... 14
Paediatrics .................................................................................................................................... 15
Physical Examination of the Neonate ........................................................................................ 15
First Antenatal Examination ....................................................................................................... 16
Paediatric Examination ENT ...................................................................................................... 16
Paediatric Chest Examination.................................................................................................... 16

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Physical Exam Reference for ACRRM formative miniCEX
Introduction

This document is designed to be used a reference when assessing physical examination skills for
the ACRRM formative miniCEX. The guide is summarised from relevant text books.
Physical examinations should be thorough and relevant to the presenting complaint.

Adults

Physical Examination of the Respiratory System

Clinical Examination: A Systematic Guide to Physicians Diagnosis
Nicholas Talley and Simon O’Connor

Position The trachea

Undressed to waist • position
Sitting over side of bed • tug
General appearance • dyspnoeic
• dyspnoea The chest
• cyanosis • inspection anterior and posterior
• characteristics of cough • shape and symmetry
o sputum o barrel chest
o stridor o pigeon chest
o hoarseness o funnel chest (pectus excavatum)
o Harrison’s sulcus
The hands
o kyphosis
• clubbing
o scoliosis
• staining
Palpitation
• wasting and weakness
• expansion
• pulse rate
• vocal fremitus
• flapping tremor (asterixis)
The face
• eyes Percussion
• nose – inside and out • liver dullness
o polyps • cardiac dullness
o engorged turbinates Auscultation
o deviated septum • breath sounds
• tongue • vocal resonance
o central cyanosis
o reddened pharynx and tonsillar The heart
enlargement Position
o rotten or broken teeth Lay down patient 45%
• sinuses • measure JVP
o palpitation • examine praecordium
o check transillumination The abdomen
• face – general skin • palpate liver
o red, leathery, wrinkled – smoker Other
o plethora • feet
cyanosis
o receding chin, and small pharynx

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Physical Exam Reference for ACRRM formative miniCEX
Physical Examination of the Cardiovascular System
Clinical Examination: A Systematic Guide to Physicians Diagnosis

Position The praecordium

Lay down patient at 45% • inspection
General appearance o scars
• respiration rapid, laboured o skeletal abnormalities
• cachectic - funnel chest
• Marfan’s syndrome - kyphoscoliosis
• Down’s syndrome - scoliosis
• Turner’s syndrome o surgical abnormalities
The hands - pacemaker
- cardioverter-defibrillator box
• clubbing
• palpation
• splinter haemorrhages
o apex beat
• Osler’s nodes
o other praecordial impulses
• Janeway lesions
• percussion
• tendon xanthomata
• auscultation
• palmar xanthomata o mitral area with bell
The arterial pulse, bilateral o mitral area with diaphragm
• rate o tricuspid area
o brachycardia/ tachycardia o pulmonary area
• rhythm o aortic area
o irregular /delete chaoticregularly o abnormalities of heart sounds
irregular - alterations in intensity
o extra beats, frequent or occasional - splitting
• radiofemoral delay - extra heart sounds
• character and volume - additional sounds
o alternating strong and weak pulse • murmurs
• Condition of vessel wall o associated features
o thickening o timing
o turtuosity o area of greatness intensity
The blood pressure, bilateral o loudness and pitch
• systolic o dynamic manoeuvres
• diastolic The neck
• pulsus paradoxus • auscultation bruits
Face The back
• sclerae for jaundice • lung bases percussion and auscultation
• xanthelasma • pitting oedema of sacrum
• mitral facies The neck
Mouth • carotid artery
• high arched palate o amplitude
• teeth diseased or broken o shape
• tongue and lips for central cyanosis o volume
• mucosa for petechiae • jugular venous pressure (JVP) pulsation
o lay down patient at 45%
o good lighting
o height and character
o abdominojugular reflux test

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Physical Exam Reference for ACRRM formative miniCEX
The abdomen The lower limbs
Position • oedema (pitting or non- pitting)
Patient lying flat with one pillow • achilles tendon xanthomata
• enlarged tender liver • cyanosis of toes
• ascites • clubbing of toes
• splenomegaly • femoral artery palpitation and auscultation
• pulsation of abdominal aorta • palpate
o popliteal
o posterior tibial
o dorsalis pedis
• atrophic skin
• loss of hair
• colour change in feet (red or blue)
• ulcers (venous, diabetic or arterial)
• reduced capillary return
o Buerger’s test
• acute arterial occlusion
• deep venous thrombosis
o tenderness and erythema
o swelling
o dilated superficial veins
o warmth
o Homan’s sign

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Physical Exam Reference for ACRRM formative miniCEX
Physical Examination of the Gastrointestinal System
Clinical Examination: A Systematic Guide to Physicians Diagnosis
Nicholas Talley and Simon O’Connor

Position • tongue
Patient lying flat one pillow o coating
General Appearance o lingua migra (black tongue)
• jaundice o geographical tongue
• weight and wasting o leukoplakia
• skin o glossitis
o pigmentation o macroglossia
o acanthosis nigricans • mouth ulcers
o hereditary haemorrahgic teleangiectasia o aphtous ulceration
o porphyria cutanea tarda o angular stomatitis
o systemic sclerosis • candidiasis (monilasis)
o mental state (encephalopathy) The neck and chest
• lymph nodes
The hands • spider naevi
• nails • gynaecomastia
o leuconychia
The abdomen
o clubbing
• the palms • inspection
o palmar erythemia o scars
o anaemia o distention
o dupuytren’s contracture o local swelling
o prominent veins
• hepatic flap
o pulsations
The arms
o visible peristalsis
• bruising o skin lesions
• petechiae o Sister Joseph nodule
• muscle wasting o discoloration of umbilicus
• scratch marks o striae
• spider naevi o asymmetrical movement
• lymphaenopathy • palpitation
The face o examine each region
• jaundice o examine tender area last
• anaemia o light to deep palpitation
• Kayser- Fleischer rings o guarding
• iritis o rigidity
• xanthelasma o rebound tenderness
• periorbital purpura • the liver
Salivary glands o liver span
• parotid enlargement o hepatomegaly
• submandibular enlargement • the gallbladder
The mouth o Murphy’s sign
• teeth • the spleen
o state of teeth • the kidneys
o gum hypertrophy
o gum pigmentation
o ulcers
• breath
o fetor
o fetor hepaticus

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Physical Exam Reference for ACRRM formative miniCEX
• other abdominal masses • percussion
o stomach and duodenum o liver
o pancreas o spleen
o aorta o kidneys
o bowel o bladder
o bladder o ascites
o inguinal lymph nodes - shifting dullness
o testes - fluid thrill
o anterior abdominal wall • auscultation
• hernias o bowel sounds
o irreducible o friction rubs
o obstructed o venous hums
o strangulated o bruits

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Physical Exam Reference for ACRRM formative miniCEX
Physical Examination of the Endocrine System
Clinical Examination: A Systematic Guide to Physicians Diagnosis
Nicholas Talley and Simon O’Connor

General Mouth
• inspect for diagnostic facies or body habitus • protrusion of chin
• body weight • enlargement of tongue
• height • buccal pigmentation
• examine urine Neck
• trousseau’s sign (tetany) • protrusion of chin
• proximal weakness • enlargement of tongue
• buccal pigmentation
Hands Chest wall
• overall size • hirsutism
• length of metacarpals • loss of hair
• abnormalities of nails • reduction breast size (women)
• tremor • gynaecomastia (men)
• palmar erythemia • nipple pigmentation
• sweating palms Abdomen
• pulse • hirsutism
Axillae • central fat deposition
• axillary hair • purple striae
• acanthosis Genitalia
• skin tags • virilisation
Eyes • atrophy
• fundi Legs
Face • diabetic changes
• hirsutism
• fine wrinkled hairless skin
• greasiness
• acne
• plethora

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Physical Exam Reference for ACRRM formative miniCEX
Physical Examination of the Nervous System
Clinical Examination: A Systematic Guide to Physicians Diagnosis
Nicholas Talley and Simon O’Connor

General Upper limbs

• handedness • motor System
• conscious level o wasting
• neck stiffness o tremor
• Kernig’s sign o
• dysarthria o tone
Cranial nerves o power
Position: o reflexes)
Sit over side of bed if possible • coordination
General inspection of head and neck • sensation
• craniotomy scars o pain
o temperature
• neurofibromas
o vibration
• facial asymmetry
o proprioception
• ptosis o light touch
• proptosis • thickened nerves
• skew deviation of eyes
Lower limbs
• inequality of pupils
• motor system
• I smell o tone
• II visual acuity and fields; fundoscopy o power
• III, IV, VI o reflexes
• V corneal reflexes • coordination
• VII facial muscles • sensation
• VIII hearing • saddle region
• IX, X palate and gag • back
• XI Trapezius and sternomastoids • gait
• XII tongue

Physical Examination of the Cervical Spine

Clinical Orthopaedic Examination: Ronald McRae

Inspection • thoracic outlet syndrome

• asymmetry in supraclavicular fossae o ischaemia of hand/s
• torticollis o pulse on traction
Palpation o Adson’s test
• tenderness o Roos test
• masses o neurological disturbance
• prominence of cervical rib with local • cord compression and cervical myelopathy
tenderness • cervical myelopathy
• enlarged cervical lymph nodes o Hoffmann’s test
• enlarged thyroid gland o dynamic Hoffmann’s test
o L Hermitte’s test
Movements
o inverted radial reflex
• head range flexion and extension
o clonus
• head range lateral flexion o myelopathy hand
• head range of rotation
• crepitus

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Physical Exam Reference for ACRRM formative miniCEX
Physical Examination of the Shoulder
Clinical Orthopaedic Examination: Ronald McRae

Inspection Rotation screening

• the front • place arm behind opposite shoulder blade
o prominent sternoclavicular joint • ask patient to draw hand away from back
o deformity of clavicle (old fracture) • place both hands behind neck
o prominent acromiclavicular joint • compare two sides
o deltoid wasting • pull elbows back gently
• the side • abduct shoulder 90, and flex elbow to right
o swelling of the joint angle
• from behind o patient to lower forearm from horizontal
o scapulae normally shaped and situated plane
• from above o raise hand keeping shoulder at 90
o swelling of the shoulder • elbows into sides and flex to 90 with hands
o deformity of clavicle forwards
o asymmetry of supraclavicular fossae • move hands laterally
Palpation • compare two hands
• anterior and lateral aspects glenohumeral • move hand to chest from facing forward
joint position
• upper humeral shaft and head via axilla • measure shoulder elevation and depression
• acromioclavicular joint • screen cervical spine
• press below acromion and abduct arm • crepitus
• length of clavicle o place hand over shoulder, abduct arm
Movement • rotator cuff
• abduction both arms noting: o abduction and drop arm test
o initiation of abduction o neer impingement sign
o passive abduction if patient unable • anterior glenohumeral instability
o smooth o apprehension test
o range of movement o relocation test
o pain o drawer test of Gerber and Ganz
o hold arm vertical position • posterior glenohumeral instability
o lower arm o drawer test
• movements restricted o jerk test
o fix angle of the scapula and try to abduct • inferior glenohumeral instability
arm o sulcus sign
o place one hand on shoulder and swing • biceps tendon instability test
arm across chest, flexed at elbow • biceps tendinitis
• forward flexion o speed test
o swing arms forward above head • integrity of the long head of biceps
o view range from side • deltoid power
• backwards flexion • suprascapular nerve
o swing arms directly backwards o supraspinatus
o view angle from side o infraspinatus
• horizontal flexion and abduction (not routine) • long thoracic nerve
o lean with both hands against the wall

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Physical Exam Reference for ACRRM formative miniCEX
Physical Examination of the Knee
Clinical Orthopaedic Examination: Ronald McRae

Inspection Movements
• swelling • extension
o confined to limits of synovial cavity and o full
suprapatellar pouch o hyperextension
o extends beyond joint cavity • flexion
• lumps o range
• discoloration • genu valgum (knock knee)
• skin marks o unilateral or bilateral
o scars o adults
o sinus scars o children
o psoriasis • genu varum (bow leg)
• temperature • instability
o knee o valgus
o foot o varus
• quadriceps o anterior displacement of tibia
o inspect/ measure wasting o posterior displacement of tibia
o examine contracted quads o rotatory
o contracted quads dorsiflex inverted foot • the menisci
• extension apparatus o tenderness in joint line
o patient sitting legs over side of couch o springy block to full extension
o patient extend leg while you hold ankle o oedema
o feel quads contraction o posterior lesions
o note position of patella o anterior lesions
o place finger along upper broader o McMurray manoeuvre for medial
o look for gaps and tenderness at other meniscus
levels o McMurray manoeuvre for lateral
• effusion meniscus
o inspection o clicks
o patellar tap test (ballottement test) o Apley’s grinding test
o fluid displacement test o meniscal cysts
o palpable fluid wave test • the patella
• haemarthrosis o examine knees flexed over couch
• pyarthrosis o tenderness
• Tenderness o Q angle
o joint line structures o mobility
o collateral ligaments o pain
o tibial tubercle o apprehension test
o patellar ligament o crepitus
o femoral condyles o examine popliteal region
o Wilson’s test o examine the hip

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Physical Exam Reference for ACRRM formative miniCEX
Physical Examination of the thoracic and lumbar spine
Clinical Orthopaedic Examination: Ronald McRae

Inspection • suspected prolapsed intervertebral disc

• from the side – normal posture • screen hips
o bend forward • straight leg raising test lying down
o stand upright and brace back and • straight leg raising sitting
shoulders to produce extension • standing apply pressure to head
o note lumbar curvature • pinch skin at sides
o stature • amount of rotation to produce pain
• from behind • tendon reflexes
o café’ au lait spots o knee jerk
o fat pad or hairy patch o ankle jerk
o surgical scarring • ask patient to dorsiflex both feet
o scoliosis
• attempt them into plantarflexion against
o note hips and shoulder level
resistance
• patient sitting
• test dorsiflexion holding toes greater and
o curvature
lesser
• bend forward
• test plantarflexion holding toes greater and
o check leg lengths
lesser
Palpation
• encircle feet with hands, test power of
• sitting leaning forward
peronei against resistance
• tenderness • pin prick sensation
o between spines
o dermatomes lower limb
o over lumbar muscles o perineal
o sacroiliac joints
• suspected thoracic cord compression
o renal
o abdominal reflexes
o higher in spine
• suspected thoracic motor root dysfunction
• standing
o lay down place hands behind head, flex
• slide fingers down lumbar spine to sacrum knees and sit up
o note any curve irregularity
• suspected ankylosing spondylitis
o change in friction
o check chest expansion at fourth
Percussion
interspace
• standing bend forward
• suspected sacroiliac joint involvement
• lightly percuss spine root of neck to sacrum o flex hip and knee and forcibly adduct hip
Movements o pelvic compression
• flexion o open out pelvis with thumbs hocked
• attempt to touch toes around anterior spines
o smoothness • abdominal examination
o areas of restriction o rectal or vaginal examination depending
o hip flexion on findings
o measure spine when erect and when • circulation
bent forward o peripheral pulses and circulation
• patient to arch back with support
• patient to slide hands down each side of leg
• patient seated and twist to each side

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Physical Exam Reference for ACRRM formative miniCEX
Mental State Examination
Clinical Examination: A Systematic Guide to Physicians Diagnosis
Nicholas Talley and Simon O’Connor

Orientation Score Max

‘What is the (year) (season) (date) (day) (month)?’ Ask for the date, then specifically ask
about the parts omitted (e.g. season). 5
Score 1 point for each correct answer
‘Where are we (country) (state) (town) (hospital) (ward)?’ Ask in turn for each place.
5
Score 1 point for each correct answer.
Registration
‘May I test your memory?’ Repeat three objectives (e.g. pen, watch, book).
Score 1 point for each correct answer.
3
Then repeat until the patient learns all three. Count trials and record up to six.
Attention and calculation
‘Count backwards from 100 by sevens.’
One point for each answer (93, 86, 79, 65)
Or spell “world” backwards 5
Score 1 point for each letter correct.
Recall
Ask patient to recall the three objects in ‘registration’, above.
Score 1 point for each correct answer. 3
Language
Ask the patient to name two objects shown (e.g. pen, and watch).
2
Score 0-2 points.
‘Repeat the following:” No ifs ands or buts”. Score 1 point. 1
Ask the patient to follow a three stage command e.g. ‘Take this paper in your right hand,
fold it in half and put on the table.’
3
Score 1 point for each step.
Read and obey the following: 1
Close your eyes. Score 1 point.
Write a sentence.
Do not dictate-must be sensible, but punctuation and grammar not essential. Score 1 1
point.
Copy this design (see below)
All ten angles must be present, and the two must intersect. Score 1 point. 1
TOTAL /30
Assess patient’s level of consciousness along a continuum
Alert Drowsy Stuporose Comma
Scores of 21-29 indicate mild cognitive impairment.
Scores below 20 indicate more sever cognitive impairment, and are likely to be due to dementia, especially
if obtained on repeated examinations

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Physical Exam Reference for ACRRM formative miniCEX
Paediatrics

Physical Examination of the Neonate

Queensland Maternity and Neonatal Clinical Guideline

Position Abdomen
effectively prepared for examination • size
General appearance • shape
• skin colour • symmetry
• anomalies • palpate organs
• alertness • umbilicus
Growth status Genitourinary structure
• head circumference • penis
• weight • foreskin
• length • testes
• plot on centile chart • clitoris
Head/face and neck • labia
• shape • hymen
• size • anus position
• fontanelles • passage of urine
• sutures • passage of stool
• eyes Back
• nose • spinal column
• ears-position • skin
• mouth • symmetry of scapulae
• palate • symmetry of buttocks
• tongue
Hips/legs and feet
• jaw
• ortolani’s manoeuver
Clavicles/arms and hands
• barlow’s manoeuver
• length
• leg length
• proportion
• proportions symmetry
• symmetry
• digits
• digits
Chest/cardiorespiratory system Neurological function
• size • posture
• shape • behaviour
• nipples • movements
• heart sounds • muscle tone
• heart rate • cry
• pulses • reflexes (moro, rooting, suck, grasp,
• breath sounds stepping)
• respiratory rate

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Physical Exam Reference for ACRRM formative miniCEX
First Antenatal Examination

Measurements Breast examination

• height • if in early pregnancy
• weight Fundal height/foetal heart rate
• BMI • if appropriate
Cardiovascular Urinalysis
• pulse Edinburgh depression scale
• blood pressure • usually will be done in maternity unit
• heart sounds Vaginal examination
Dental review • pap smear if due

Paediatric Examination ENT

Interacts with the child appropriately Mouth
Ensures child is held in a safe position for the • lips
examination • gingiva
Ears • teeth
• shape/Size/Position pinnae • mucosa
• preauricular lesions • tongue
• external ear canal • palate
• otoscopic examination • pharynx
Nose • tonsils: size/symmetry/exudate
• shape Neck
• size • shape
• position • height
• inspection of internal structures • neck vessels
• masses
• nodes
• thyroid

Paediatric Chest Examination

General appearance Heart
• chest wall • peripheral pulses
• symmetry • palpation of heart
• shape Lungs
• nipple alignment • Auscultation
• breathing pattern
Breasts

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Physical Exam Reference for ACRRM formative miniCEX
Australian College of Rural and Remote Medicine
Level 2, 410 Queen Street, Brisbane, Qld 4000
GPO Box 2507
P: 07 3105 8200
F: 07 3105 8299
E: acrrm@[Link]
ABN 12 078 081 848