Examination – 101

When asked about examination we can use the Talley and O’Connor approach, starting with general inspection and then progressing up from the hands.

General Approach

In clinical examination, we use some generic techniques

  • General Inspection and basic observations – T, P, BP, RR, SaO2, Height, Weight, BMI
  • Inspection, Palpation, Percussion, and Auscultation apply in general medicine and surgery
  • Look, feel, move applies to orthopaedics
  • Circulation, sensation, and motor apply in trauma
  • Sensation and motor (tone, power, reflexes) apply in neurology
  • Special tests

General Inspection

  1. Patient’s General Condition:
    • This includes observing the patient’s general state of health, build, and posture.
    • Is the patient well-looking or ill-looking?
    • Are they comfortable at rest or in distress?
  2. Gait: 
    • This can provide insights into a number of conditions, from arthritis to Parkinson’s disease
  3. Signs of Distress:
    • Note if the patient is in pain, breathless, or anxious.
  4. Odours:
    • Certain smells can be associated with specific medical conditions, like the sweet, fruity odour in diabetic ketoacidosis
  5. Hygiene and Dress:
    • This can give clues to the patient’s socio-economic status, level of self-care, or possible neuropsychiatric conditions.
  6. Eye Contact and Body Language: 
    • This can provide insights into possible neuropsychiatric conditions.
  7. Basic Observations: T, P, BP, RR, SaO2, Height, Weight, BMI
    • Temperature
    • Pulse
    • Blood Pressure
    • Respiratory Rate
    • SaO2
    • Height
    • Weight
    • BMI

Talley and O’Connor’s approach

Examining the hands and moving up the arm is an essential part of many systemic examinations. Here’s a detailed breakdown:

Hands:

  1. Temperature:
    • Cold hands may indicate poor peripheral perfusion, seen in conditions like shock or peripheral vascular disease.
  2. Colour:
    1. Cyanosis: Bluish discoloration, suggesting poor oxygenation.
    2. Pallor: Paleness of the palmar creases might indicate anemia.
  3. Nails:
    1. Clubbing: Seen in a variety of conditions, including lung cancer, interstitial lung diseases, cystic fibrosis, congenital heart disease, and infective endocarditis.
    2. Koilonychia: Spoon-shaped nails, often associated with iron-deficiency anemia.
    3. Leukonychia: White spots, common and usually benign.
    4. Onycholysis: Separation of the nail from the nail bed is seen in onychomycosis, psoriasis, thyroid disease, and iron deficiency.
    5. Terry’s nails: Mostly white nails with a band of reddened or darker colour at the tip, which are associated with cirrhosis, CKD, and CCF.
    6. Beau’s lines are indentations that run across the nails, suggesting an interruption in growth during severe illness.
  4. Joint changes:
    • Swelling or deformities might indicate rheumatoid arthritis, osteoarthritis, or other joint diseases.
  5. Palm:
    1. Palmar erythema: Reddened palms, seen in conditions like liver disease, rheumatoid arthritis, or pregnancy.
    2. Dupuytren’s contracture: Thickened tissue causing fingers to pull into the palm.
  6. Wrist:
    1. Tendon xanthomas: Nodules on the tendons, typically associated with certain types of hyperlipidemia.
    2. Pulses: Check radial pulse for rate, rhythm, and character.

Moving up the Arm:

  1. Blood Pressure:
    • Measured typically on the upper arm using a sphygmomanometer.
  2. Arm symmetry:
    • Look for muscle wasting or asymmetry.
  3. Crepitus:
    • This can be felt over the elbow in rheumatoid arthritis.
  4. Elbow:
    1. Rheumatoid nodules: These can be felt at the extensor surface of the ulna.
    2. Cubital fossa: Check for any lumps, bumps, or AV fistula (in patients undergoing hemodialysis).
    3. Track marks: IVDU
  5. Lymph Nodes:
    • Check for axillary lymphadenopathy.

Shoulders (as for any joint – look/feel/move):

  1. Inspection:
    • Look for muscle bulk and symmetry.
  2. Palpation:
    • Feel for warmth, tenderness, or swelling.
  3. Movement (active and passive):
    1. Active: Ask the patient to move their shoulders in various planes to check for any restriction or pain.
    2. Passive: The examiner moves the shoulder in various planes to check for any restriction or pain.

Lateral Neck:

  1. Lymph Nodes:
    • Palpate the cervical chain of lymph nodes for any swelling or tenderness.
    • Lymphadenopathy might be suggestive of infections, malignancies, or other inflammatory conditions.
  2. Supraclavicular Nodes (Virchow’s node):
    • Associated with stomach cancer, lung cancer, esophageal and lymphomas, as well as sarcoid and TB.

Ears:

  1. Inspection:
    • Pinna: Look for deformities, nodules, or skin lesions.
    • External auditory canal: Check for wax, discharge, inflammation, or foreign bodies.
  2. Hearing:
    • You might do a whispered voice test or use a tuning fork to perform a basic hearing assessment.
      1. Rinne test: Air conduction is better than bone unless conductive hearing loss
      2. Weber tests: Sound localises to the side of conductive hearing loss or away from the side of sensorineural loss

Eyes:

  1. Inspection:
    • Conjunctiva: Check for pallor (anemia) or jaundice.
    • Sclera: Look for jaundice or other discolourations.
    • Pupils: Assess size, shape, symmetry, and reactions to light.
  2. Fundoscopy:
    • Examine the retina, where you might find signs related to hypertension, diabetes, or other conditions.

Nose:

  1. Inspection:
    • Check for deformities, inflammation, or discharge.
  2. Patency:
    • Ask the patient to occlude one nostril at a time to assess for any obstruction.

Mouth and Throat:

  1. Lips:
    • Look for cyanosis, pallor, cracking and angular cheilitis.
  2. Teeth:
    • Check for dental hygiene, missing teeth, or dental caries.
  3. Gums:
    • Assess for inflammation, swelling, or bleeding.
  4. Tongue:
    • Look for any ulcers, discolourations, or atrophy.
  5. Palate and Oropharynx:
    • Inspect for symmetry, lesions, tonsil size, or any exudate.

Neck (Midline):

  • Thyroid gland:
    • Inspect for enlargement or nodules, then palpate for size, consistency, and tenderness.
  • Carotids:
    • Assess pulse form and for any bruits.
  • Trachea:
    • Check if it’s central or deviated.

Chest:

  1. Inspection:
    • Observe for shape, symmetry, scars, or deformities like pectus excavatum or pectus carinatum.
  2. Palpation:
    • Feel for tenderness, masses, or crepitus.
  3. Percussion:
    • Check for resonance and areas of dullness.
  4. Auscultation:
    • Listen to breath sounds, noting any wheezing, crackles, or reduced breath sounds.
    • Listen to heart sounds in all 4 areas, including rubs.
    • Erb’s point – left 3rd ICS is the best general location to listen.

Abdomen:

  1. Inspection:
    • Observe contours, scars, visible peristalsis, or masses.
  2. Auscultation:
    • Before palpation, listen for bowel sounds and any vascular bruits.
  3. Percussion:
    • Helps assess the size of the liver and spleen and detect any fluid or masses.
  4. Palpation:
    • Begin with light palpation, moving to deeper palpation to assess for masses, organ enlargement, tenderness, guarding and rebound
  5. Special maneuvers:
    • Depending on initial findings, you might perform special tests or maneuvers, like checking for ascites or specific causes of pain.

Legs:

  1. Swelling (Oedema):
    • This can be a sign of heart failure, kidney disease, venous insufficiency, or lymphatic obstruction.
    • Pitting edema, where a pressed finger leaves a dent, is particularly noteworthy.
  2. Skin Changes:
    1. Dry, flaky, or itchy skin might be due to dermatological conditions or systemic illnesses like hypothyroidism.
    2. Ulcers, especially around the ankles, could indicate arterial or venous insufficiency.
    3. Pale or bluish skin and loss of hair can indicate chronic arterial insufficiency.
    4. Redness could suggest cellulitis or deep vein thrombosis.
  3. Varicose Veins:
    • Enlarged, swollen, and twisting veins, usually appearing blue or dark purple, could indicate venous insufficiency.
  4. Temperature Changes:
    • Cold legs can suggest arterial blockages, while warmth might indicate an underlying infection or inflammation.
  5. Joint Swelling:
    • Swelling in the knee or ankle joints might indicate arthritis or injury.
  6. Muscle Wasting:
    • Atrophy of the leg muscles can be a sign of disuse, neurological conditions, or muscle diseases.
  7. Muscle Strength:
    • Reduced muscle strength can be a sign of neuromuscular disorders or disuse atrophy.
  8. Bilateral Symmetry:
    • Comparing both legs for symmetry in size, color, and other features is important to identify unilateral abnormalities.
  9. Sensation:
    • Loss of sensation, tingling, or burning (neuropathy) in the legs can be due to diabetes, neurological disorders, or circulatory problems.
  10. Pain:
    • Pain on walking that is relieved with rest (claudication) is a classic sign of Peripheral Arterial Disease. Pain, swelling, and redness might suggest thrombophlebitis or deep vein thrombosis.
  11. Nail Changes:
    • Thickening or discolouration of toenails can be a sign of fungal infections or may reflect systemic health issues.
  12. Gait:
    • The way a person walks can reveal a lot about leg health – limping, inability to bear weight, or favoring one leg may indicate underlying issues.